Chapter 16: Infection Prevention and Control: Protective Mechanisms and Asepsis My Nursing Test Banks

Chapter 16: Infection Prevention and Control: Protective Mechanisms and Asepsis

Test Bank

MULTIPLE CHOICE

1. When a patient in the ambulatory clinic is diagnosed as having pneumococcal pneumonia, the nurse is aware that this infection is:

a.

viral and will not respond to antibiotics.

b.

bacterial and should respond to treatment with antibiotics.

c.

fungal and is caused by the alteration of the normal flora of the lung.

d.

resultant from a resistant organism and extreme caution must be taken.

ANS: B

The coccal suffix indicates a bacterial infection with round cocci, which are bacteria that usually respond to antibiotic therapy.

DIF: Cognitive Level: Comprehension REF: p. 209 OBJ: Theory #1

TOP: Infectious Agents KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: physiological adaptation

2. The nurse explains to the patient who has pneumococcal pneumonia that the lungs serve as the:

a.

mode of transfer.

b.

transmission of the disease.

c.

reservoir.

d.

organisms that cause the infection.

ANS: C

The reservoir is the place where the organism is found, such as a wound or, in this case, the infected lungs. Droplets are modes of transmission from the reservoir.

DIF: Cognitive Level: Comprehension REF: p. 212 OBJ: Theory #2

TOP: Process of Infection KEY: Nursing Process Step: N/A

MSC: NCLEX: Physiological Integrity: physiological adaptation

3. The patient inquires about how his body will kill pathogens unassisted by antibiotics. The nurse responds that a process called phagocytosis will:

a.

stimulate the body to make more white blood cells.

b.

create antibodies against the pathogen.

c.

engulf and destroy the pathogen.

d.

stimulate the production of interferons.

ANS: C

Phagocytes that are stored in the GI tract, liver, and spleen kill pathogens by engulfing and destroying the invaders and cleaning up the debris.

DIF: Cognitive Level: Comprehension REF: p. 208 OBJ: Theory #5

TOP: Body Defenses KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: physiological adaptation

4. The nurse explains that the immunizations against hepatitis B will:

a.

stimulate the body to make antibodies the hepatitis B antigen.

b.

offer immediate protection from hepatitis B by the injection of ready-made antibodies.

c.

introduce live antigens into the body that will stimulate the production of antibodies.

d.

offer protection against hepatitis A, C, and D, in addition to hepatitis B.

ANS: A

Artificially acquired immunization is achieved by introducing killed or attenuated pathogens that are recognized as antigens by the immune system but that are not able to cause disease. These antigens stimulate the formation of antibodies specific to hepatitis B only.

DIF: Cognitive Level: Comprehension REF: p. 218 OBJ: Theory #5

TOP: Immune Response KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: physiological adaptation

5. A mother and her 2-week-old infant, who is breast-fed, have been exposed to chickenpox. Although the mother had chickenpox as a child, she is concerned about her baby. The nurse explains:

a.

the infant is at risk because the baby has not been immunized against the disease.

b.

both infant and mother are at risk because the mothers immunity was acquired too long ago to be effective.

c.

the baby should receive immune globulin to protect him from the infection.

d.

neither are at risk, because the mother has naturally acquired immunity, and she passes antibodies to the baby through the breast milk.

ANS: D

Having had a disease such as chickenpox provides lifelong naturally acquired immunity, which allows the mother to pass on antibodies through the placenta and breast milk to protect the infant until his immune system is more mature.

DIF: Cognitive Level: Analysis REF: p. 218 OBJ: Theory #4

TOP: Immune Response KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: physiological adaptation

6. Health personnel should wash their hands with soap and water at the beginning of the shift for:

a.

10 seconds.

b.

15 seconds.

c.

1 minute.

d.

2 minutes.

ANS: B

Hand hygiene as suggested by the CDC should be done at the beginning of the shift for 15 seconds (30 seconds or longer in specialty areas).

DIF: Cognitive Level: Knowledge REF: p. 221 OBJ: Clinical Practice #2

TOP: Asepsis KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

7. An organism that is included in the extended-spectrum beta-lactamase producing pneumonia (ESBL) group is:

a.

Staphylococcus aureus.

b.

Clostridium difficile.

c.

Enterococcus.

d.

Escherichia coli.

ANS: D

E. coli and Klebsiella pneumoniae are the organisms in the ESBL group.

DIF: Cognitive Level: Knowledge REF: p. 209 OBJ: Theory #1

TOP: Resistant Organisms KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

8. The nurse explains that medical asepsis differs from surgical asepsis in that medical asepsis:

a.

kills all organisms.

b.

is confined to the patients room.

c.

uses sterile attire to protect the patient.

d.

uses sterile equipment before contact with the patient.

ANS: B

Medical asepsis confines the microorganisms to the patients room. Medical asepsis does not kill all organisms; it uses clean attire and equipment.

DIF: Cognitive Level: Comprehension REF: p. 218 OBJ: Theory #7

TOP: Medical Asepsis KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

9. When the nurse performs a procedure using sterile technique in the patients unit, it means that:

a.

the equipment and supplies used are disposable and clean.

b.

all organisms have been killed or removed from materials that come in contact with the patient.

c.

the nurse will do a 10-minute surgical scrub before beginning the procedure.

d.

the nurse will be required to don a sterile gown, mask, and eye shields.

ANS: B

Surgical asepsis or sterile technique uses sterilization to remove all organisms, not just pathogens. The purpose is to protect the patient from the introduction of organisms that could endanger health. Although sterile gloves are used, there is no need for a sterile gown.

DIF: Cognitive Level: Comprehension REF: p. 218 OBJ: Theory #7

TOP: Asepsis KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

10. A nurse teaching family members about hand hygiene in the home would emphasize:

a.

keeping fingernails short and avoiding wearing rings.

b.

washing hands up to the elbows for 2 minutes the first time in the day, and for 1 minute after a diaper change.

c.

using disposable gloves after hand hygiene when feeding the infant.

d.

that home care requires less attention to medical asepsis, so hand hygiene is necessary only after toileting or handling soiled diapers.

ANS: A

Fingernails and jewelry provide hiding places for organisms and can scratch the baby. A 10- to 20-second hand hygiene routine is appropriate before handling the baby and after changing diapers (as well as after toileting, before eating, and anytime they are soiled).

DIF: Cognitive Level: Application REF: p. 219 OBJ: Clinical Practice #2

TOP: Medical Asepsis KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

11. A nurse is using personal protective equipment (PPE) before entering the room of a patient with diarrhea and vomiting who is being treated for an intestinal infection. The nurse most likely needs to use which combination of PPE?

a.

Gown, gloves, and mask

b.

Gown, gloves, and goggles (or glasses)

c.

Shoe covers, gown, and gloves

d.

Reusable gown and mask

ANS: B

The gown is necessary to protect the nurses uniform from becoming contaminated with organisms from stool or vomitus, gloves protect hands from contact with these body secretions, and goggles prevent splashing of contaminated material into the eyes. Protective gowns are not reused.

DIF: Cognitive Level: Application REF: p. 228, Skill 16-2

OBJ: Clinical Practice #3 TOP: Standard Precautions

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

12. When removing a used face mask, the nurse correctly:

a.

lowers it below his chin to use the next time he enters that patients room.

b.

removes the mask first before removing any other PPE.

c.

unties the bottom ties first, then the top, and disposes of the mask without touching it.

d.

discards the mask only if it is wet; otherwise, he folds and stores it to reuse the next time.

ANS: C

Face masks are not reused, and they should not be worn dangling around the neck. Gloves should be removed first (and eyewear, if worn) before removing the mask so as not to contaminate the nurses hair or face.

DIF: Cognitive Level: Comprehension REF: p. 228, Skill 16-2

OBJ: Clinical Practice #3 TOP: Standard Precautions

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

13. The nurse uses the Standard Precautions, as outlined by the Centers for Disease Control and Prevention (CDC), when:

a.

there is a suspicion of or risk of infection.

b.

preventing transmission of respiratory and wound infections.

c.

caring for patients who have wounds draining body fluids.

d.

caring for all patients.

ANS: D

Standard Precautions include hand hygiene and use of PPE when there is exposure to blood, body fluids, mucous membranes, nonintact skin, secretions, excretions, and contaminated articles. Hand hygiene is part of patient care for all patients all the time, regardless of diagnosis, and the selection of PPE is appropriate for all patients at some time or another.

DIF: Cognitive Level: Application REF: p. 224, Box 16-3

OBJ: Clinical Practice #3 TOP: Standard Precautions

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

14. When the nurse is using a syringe and needle to give a patient an injection, he or she should:

a.

never recap the needle afterwards to avoid risk of needle stick.

b.

carefully break the needle from the syringe, using the needle cover to prevent reuse of a used syringe and needle.

c.

throw the needle and syringe immediately in a covered garbage can with a red plastic liner to indicate the materials are biohazards.

d.

recap the needle and place it carefully on the patients table until leaving the room, then discard it in a garbage container in the nurses medication room.

ANS: A

Used needles and sharps need to be handled very carefully to prevent sticks with contaminated body fluids (blood). Never recapping the needle is an approved CDC Standard Precaution. The other choices are contraindicated. Sharps should be discarded in a specially marked container that does not endanger the person who empties it. The needle should not be broken or recapped unless it is done with a one hand scoop method. Throwing needles or sharps in a red plastic bag endangers others.

DIF: Cognitive Level: Application REF: p. 229 OBJ: Clinical Practice #3

TOP: Standard Precautions KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

15. The nurse using protective non-sterile gloves in the provision of patient care will wash his or her hands after removal of the gloves in order to:

a.

avoid transfer of organisms.

b.

diminish possibility of latex allergy.

c.

keep skin of hands from cracking and drying.

d.

enhance the ease of donning a fresh pair of gloves.

ANS: A

Washing the hands immediately after removing barrier gloves decreases the likelihood that organisms will gain access to the skin through small holes or imperfections in the gloves and reduces the transfer of microorganisms to the environment and other persons.

DIF: Cognitive Level: Comprehension REF: p. 218, Box 16-3

OBJ: Clinical Practice #2 TOP: Standard Precautions

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

16. The nurse encourages the 84-year-old patient who is recovering from a hip replacement to:

a.

cough frequently to make up for the loss of cilia.

b.

restrict fluid to prevent pulmonary congestion.

c.

keep the bed flat to aid in lung expansion.

d.

encourage bed rest.

ANS: A

Because of the loss of an adequate cough mechanism and loss of cilia, the mature adult should be encouraged to cough frequently.

DIF: Cognitive Level: Application REF: p. 21, Table 16-6

OBJ: Theory #3 TOP: Prevention of Infection in the Elderly

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

17. A patient is sent home with an open wound that is still infected and being treated with wet-to-dry dressing changes four times a day. Before discharge, in order to prevent infecting other family members, the nurse would teach the patient to:

a.

be the only person to perform the dressing changes, thus eliminating the risk of infection to other family members.

b.

wash hands thoroughly before the dressing change.

c.

use gowns, gloves, and masks for any family contact with him.

d.

maintain medical asepsis and proper handling of the contaminated dressings.

ANS: D

Medical asepsis is the most important way of preventing the spread of infection in the home or in the hospital or nursing home.

DIF: Cognitive Level: Application REF: p. 224, Box 16-3

OBJ: Clinical Practice #4 TOP: Asepsis in the Home Environment

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

18. The nurse instructing a patient in the home use of disinfectant would include the information that the disinfectant can be used to:

a.

decrease organisms on the patients body but take care not to use it around the patients eyes or in the mouth.

b.

sterilize instruments with a bacteriostatic disinfectant.

c.

thoroughly clean and rinse all soap off the equipment before disinfecting it.

d.

first remove all organic matter prior to disinfecting.

ANS: C

Disinfectants are irritating to the skin. Bacteriostatic disinfectants only weaken or slow the growth of organisms; they do not kill them. Hot water hardens organic matter; therefore equipment should be rinsed with cold water before hot soapy water is used.

DIF: Cognitive Level: Comprehension REF: p. 230 OBJ: Theory #6

TOP: Disinfection KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

19. The nurse is aware that the use of ethylene oxide gas is reserved for the sterilization of:

a.

dressings.

b.

surgical instruments.

c.

heat-sensitive items.

d.

floors and walls.

ANS: C

Ethylene oxide is used to sterilize heat-sensitive items and offers good penetration.

DIF: Cognitive Level: Knowledge REF: p. 230 OBJ: Theory #8

TOP: Cleaning and Disinfection KEY: Nursing Process Step: Planning

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

20. The nurse recommends a good agent for disinfecting contaminated areas in the home is:

a.

to cover the area with boiling water and let air dry.

b.

a 1:10 solution of chlorine bleach.

c.

a 1:2 solution of alcohol.

d.

to soak in a solution of povidone-iodine for 30 minutes and rinse with hot water.

ANS: B

A 1:10 solution of chlorine bleach is a good home disinfectant.

DIF: Cognitive Level: Comprehension REF: p. 230 OBJ: Theory #8

TOP: Asepsis in the Home Environment KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

21. The situation in which protective eyewear is required is:

a.

suctioning a tracheotomy.

b.

applying a dressing on the leg.

c.

changing a babys diaper.

d.

gathering the linens off a contaminated bed.

ANS: A

Suctioning a tracheotomy causes the patient to cough and spray mucus. Protective eyewear is used when there is danger of splashing blood or body fluids, such as in the operating room. It is not necessary in the other situations.

DIF: Cognitive Level: Application REF: p. 226, Skill 16-2

OBJ: Clinical Practice #3 TOP: Standard Precautions

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

22. To prevent a urinary infection in an elderly patient who is in traction for a broken femur, the nurse would:

a.

request a Foley catheter to be inserted.

b.

encourage fluid intake to keep urine dilute.

c.

encourage intake of apple juice to keep urine acidic.

d.

offer a urinal every 2 hours.

ANS: B

Encouraging fluid intake to keep urine dilute would be the best way to prevent a urinary infection because concentrated urine is a good medium for pathogens.

DIF: Cognitive Level: Application REF: p. 215, Table 16-6

OBJ: Theory #3 TOP: Urine Infections in the Elderly

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

23. Fecal matter has contaminated the patients bed sheet. The nurse should:

a.

place a folded clean, dry sheet or plastic-backed protector over the soiled sheet until it dries and then change the sheet.

b.

don non-sterile gloves and gown, remove the soiled sheet, replace it with a clean one, and then dispose of the sheet in a plastic bag to prevent skin or clothing contact.

c.

remove the soiled sheet without exposure of skin or clothing to the sheet and rinse it in the patients bathroom sink to dilute or remove as much feces as possible.

d.

use PPE to remove the sheet and place it in a pillowcase on the floor; then replace it with a clean sheet.

ANS: B

When handling, transporting, or processing linens contaminated with blood or body fluids, prevention of contact with skin, mucous membranes, and clothing or transfer of organisms to the environment is most important. The sheets should not be rinsed in the patients room, nor should they ever be placed on the floor (clean or soiled).

DIF: Cognitive Level: Application REF: p. 224, Box 16-3

OBJ: Clinical Practice #3 TOP: Standard Precautions

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

24. The nurse explains that the bodys normal flora serve as:

a.

aids to digestion and blood production.

b.

prevention to the colonizing of pathogens.

c.

managers of fluid balance of the body.

d.

cell rebuilders.

ANS: B

Normal flora of the body prevent harmful microorganisms from colonizing and multiplying.

DIF: Cognitive Level: Comprehension REF: p. 208 OBJ: Clinical Practice #3

TOP: Prevention of Infection KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: physiological adaptation

25. A patient has been diagnosed with Creutzfeldt-Jakob disease (mad cow disease). The nurse recognizes this disease is caused by a:

a.

prion.

b.

virus.

c.

protozoa.

d.

fungus.

ANS: A

Prions are protein particles that lack nucleic acids and are not inactivated by usual procedures for destroying viruses. They do not trigger an immune response but instead cause degenerative neurologic disease such as variant Creutzfeldt-Jakob disease (mad cow disease).

DIF: Cognitive Level: Knowledge REF: p. 209 OBJ: Theory #1

TOP: Disease KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: physiological adaptation

26. A patient has been diagnosed with Rocky Mountain spotted fever. The nurse recognizes this disease is caused by a tick bite that infected the patient with:

a.

Rickettsia rickettsii.

b.

Rickettsia prowazekii.

c.

Coxiella burnetii.

d.

Aspergillus.

ANS: A

Rickettsia rickettsii is the rickettsia responsible for Rocky Mountain spotted fever.

DIF: Cognitive Level: Knowledge REF: p. 211 OBJ: Theory #1

TOP: Disease KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: physiological adaptation

27. The nurse is aware that family education is necessary for the control of the most common helminth infection, which is:

a.

hook worms.

b.

tape worms.

c.

pinworms.

d.

round worms.

ANS: C

Pinworms are the most common helminth infection, usually seen in children. Families must be educated about the control of these parasites.

DIF: Cognitive Level: Knowledge REF: p. 210 OBJ: Theory #1

TOP: Helminth Infection KEY: Nursing Process Step: Planning

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

28. A patient has been diagnosed with vaginal candidiasis. The nurse recognizes that this condition is usually the result of:

a.

unprotected sex.

b.

poor personal hygiene.

c.

long-term antimicrobial therapy.

d.

using bath oils.

ANS: C

Long-term microbial therapy can alter the vaginal flora and cause fungal infections such as vaginal candidiasis.

DIF: Cognitive Level: Knowledge REF: p. 210 OBJ: Theory #1

TOP: Candidiasis KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: physiological adaptation

29. A young patient became ill with mononucleosis that she contracted from drinking out of the same glass as her boyfriend who also had the disease. The glass, an inanimate object, has caused the indirect transmission. The inanimate transmitter is called:

a.

fomite.

b.

prions.

c.

vector.

d.

interferon.

ANS: A

A fomite is an inanimate object that can transmit pathogens indirectly.

DIF: Cognitive Level: Comprehension REF: p. 212 OBJ: Theory #2

TOP: Disease KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

30. The nurse instructs a patient that in order to reduce diseases that are transmitted via droplet, the nose and mouth should be covered by:

a.

moistened towelette.

b.

handkerchief.

c.

clean paper tissue.

d.

bent elbow.

ANS: D

Covering the mouth with a bent elbow prevents the respirator droplets from contaminating the hands.

DIF: Cognitive Level: Comprehension REF: p. 212 OBJ: Theory #2

TOP: Prevention of Disease KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

31. The nurse is aware that the first barrier to pathogen invasion is the:

a.

skin.

b.

immunizations.

c.

good hygiene.

d.

immune response.

ANS: A

Skin is the first barrier to pathogen invasion.

DIF: Cognitive Level: Knowledge REF: p. 213 OBJ: Theory #4

TOP: Prevention of Disease KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: physiological adaptation

32. An enzyme found in the mucous membranes that is bactericidal is:

a.

lysozyme.

b.

ptyalin.

c.

serotonin.

d.

histamine.

ANS: A

Lysozyme is an enzyme found in the mucous membranes, tears, and saliva, which is bactericidal and helps with disease prevention.

DIF: Cognitive Level: Knowledge REF: pp. 213-214 OBJ: Theory #2

TOP: Prevention of Disease KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

33. A nurse is caring for a patient who was exposed to Bacillus anthracis. The nurse should wash her hands with:

a.

soap and water.

b.

alcohol wipes.

c.

chlorhexidine.

d.

an antiseptic.

ANS: A

If exposure to Bacillus anthracis is suspected or proven, hands must be washed with soap and water. The physical action of washing and rinsing hands is recommended because alcohols, chlorhexidine products, iodophors, and other antiseptic agents have poor activity against spores.

DIF: Cognitive Level: Application REF: p. 226, Box 16-2

OBJ: Theory #6 TOP: Hand Washing

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

34. After reading a differential blood count on a patient, the nurse assesses that the patients infection is viral because the:

a.

monocyte count is increased.

b.

number of basophils is greatly elevated.

c.

monocyte and neutrophil counts are decreased.

d.

neutrophil count is decreased and the monocyte and the lymphocyte counts are both elevated.

ANS: D

A viral infection will show a decreased neutrophil count with an elevation of monocytes and lymphocytes.

DIF: Cognitive Level: Analysis REF: p. 216 OBJ: Theory #4

TOP: Viral Infection KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: physiological adaptation

COMPLETION

35. Fleas, ticks, mosquitoes, and other insects that harbor infection are called _____________.

ANS:

vectors

Fleas, ticks, mosquitoes, and other insects that harbor infection and transmit disease through bites are called vectors.

DIF: Cognitive Level: Knowledge REF: p. 212 OBJ: Theory #2

TOP: Infection Control KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

36. The elderly should receive influenza immunization every ______.

ANS:

year

Influenza immunizations are recommended to be taken every year by the elderly, health care workers, infants over the age of 6 months, and persons with chronic illnesses.

DIF: Cognitive Level: Comprehension REF: p. 215, Table 16-6

OBJ: Theory #3 | Theory #8 TOP: Influenza Immunization

KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

37. The nurse is aware that gram-negative bacteria are capable of causing hemorrhagic shock by the production of a(n) ______.

ANS:

endotoxin

Gram-negative bacteria are more dangerous than gram-positive bacteria because they produce an endotoxin that can cause hemorrhagic shock.

DIF: Cognitive Level: Comprehension REF: p. 209 OBJ: Theory #1

TOP: Gram-Negative Bacteria KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: physiological adaptation

MULTIPLE RESPONSE

38. Portal of exit transmission can be controlled by: (Select all that apply.)

a.

treating infected patients.

b.

isolation techniques.

c.

effective inoculations.

d.

improved hygiene.

e.

barrier precautions.

ANS: A, B, E

Portal of exit transmission can be controlled by identifying and treating infected patients, isolation techniques, barrier precautions, and proper handling of secretions, urine, feces, and exudates.

DIF: Cognitive Level: Comprehension REF: p. 212 OBJ: Theory #2

TOP: Body Defenses KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

39. The elderly are more susceptible to infection for a variety of reasons. The nurse should be aware in planning care of elderly patients that the elderly are at risk due to: (Select all that apply.)

a.

increased gastric secretions.

b.

increased macrophage activity in the lungs.

c.

delayed immune response.

d.

impaired thorax expansion.

e.

urine stasis.

ANS: C, D, E

Because the elderly have decreased gastric secretion, decreased macrophage activity in the lungs, immediate and delayed immune response, impaired thorax expansion, and urine stasis, they are prone to infection.

DIF: Cognitive Level: Comprehension REF: p. 215, Table 16-6

OBJ: Theory #3 TOP: Susceptibility of the Elderly

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: physiological adaptation

40. The nurse outlines characteristics that affect the virulence of microorganisms, which include: (Select all that apply.)

a.

sensitivity to heat.

b.

adherence to mucosal surfaces.

c.

secretion of enzymes.

d.

secretion of toxins.

e.

penetration of mucous membranes.

ANS: B, D, E

The virulence of a microorganism is affected by the ability to adhere to and penetrate mucosal membranes, multiply in the body, secrete harmful toxins, resist phagocytosis, and bind with iron.

DIF: Cognitive Level: Comprehension REF: p. 210 OBJ: Theory #1

TOP: Virulence KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: physiological adaptation

OTHER

41. Place the process of an inflammatory response in the appropriate sequence. (Separate letters with a comma and space as follows: A, B, C, D, E.)

A. Release of histamine

B. Edema or swelling

C. Redness

D. Cell injury

E. Vasodilation

ANS:

D, E, C, B, A

After a cell injury the inflammatory response stimulates vasodilation, which brings blood and fluid to the injury site causing redness and then edema. Histamine and serotonin are released, which make the capillaries more permeable to allow defensive cells to surround the damaged cells.

DIF: Cognitive Level: Analysis REF: p. 216 OBJ: Theory #5

TOP: Inflammatory Response KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: physiological adaptation

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