Chapter 8. Nursing Care of Patients With Infections My Nursing Test Banks

Chapter 8. Nursing Care of Patients With Infections

Multiple Choice
Identify the choice that best completes the statement or answers the question.

____ 1. A patient says to the nurse, what is a culture? What would be the best response by the nurse?
a. A culture measures the level of an antibiotic.
b. A culture identifies an antibiotics effect on a pathogen.
c. A culture determines the appropriate medication dosage to be used.
d. A culture identifies the presence of disease-causing microorganisms.
____ 2. The nurse reviews the method of transmission of Rocky Mountain spotted fever with a patient being treated for the disease. On which mode of transmission for the disease should the nurse focus with the patient?
a. Droplet
b. Airborne
c. Vector-borne
d. Vehicle-borne
____ 3. There are limited amounts of influenza vaccine currently available in the clinic. Which individual should the nurse identify as having the highest priority to receive vaccination at this time?
a. A 15-year-old who plays ice hockey
b. A 26-year-old with three young children
c. A 49-year-old who works in food services
d. An 88-year-old who lives in an apartment for senior citizens
____ 4. The nurse is discharging a patient who has been treated for conjunctivitis. Which patient statement indicates that teaching was effective?
a. I will have to wear a mask for 2 weeks.
b. I will not share towels with others in the house.
c. I will need to have a special air filter running at all times.
d. I must stay 3 feet away from people when talking to them.
____ 5. The nurse is reviewing patient care needs with a nursing assistant. Which intervention should the nurse explain as being the most important means of preventing the spread of infection?
a. Gloving
b. Gowning
c. Hand washing
d. Wearing a mask
____ 6. The nurse wants to ensure that a hospitalized patient with a healthy immune system does not contract an infectious disease. What nursing action should the nurse identify to reduce this patients susceptibility to an infection?
a. Planning adequate nutrition
b. Daily bathing with soap and water
c. Assessing vital signs every 4 hours
d. Admitting the patient to a private room
____ 7. The nurse is caring for a patient with influenza. For which reason should the nurse encourage the patient to increase fluids?
a. Decrease metabolism
b. Liquefies pulmonary secretions
c. Dilute bacterial serum concentration
d. Dilute bacterial urinary concentration
____ 8. During data collection, a patient is experiencing warmth, redness, swelling, and minimal drainage of the right great toe. Which health problem should the nurse recognize is occurring with the patient?
a. Local infection
b. Systemic infection
c. Generalized infection
d. Bacterial colonization
____ 9. A patient develops a hospital-acquired surgical wound infection. Which organism should the nurse recognize as being the most likely cause of this infection?
a. Shigella
b. Salmonella
c. Campylobacter
d. Staphylococcus aureus
____ 10. During data collection, the nurse suspects a patient is experiencing a urinary tract infection. Which manifestation did the nurse use to come to this conclusion?
a. Diarrhea
b. Vomiting
c. Voiding frequency
d. Abdominal distention
____ 11. The nurse is providing care to a patient with a fractured femur who is in traction. Which nursing intervention is the highest priority for the nurse to implement?
a. Increase daily fluid intake.
b. Weigh patient each morning.
c. Teach patient to cough and deep breathe.
d. Teach patient to cover mouth when coughing.
____ 12. The nurse is caring for a patient with tuberculosis (TB). What action should the nurse take before entering this patients room?
a. Wear a surgical mask with elastic straps.
b. Wear a clear plastic shield over the face.
c. Wear protective plastic goggles over the eyes.
d. Wear a fitted high-efficiency particulate air respirator.
____ 13. The nurse is assisting with the reorganization of the clean utility room. Which item should the nurse consider as being surgically aseptic?
a. An unsealed package in a cupboard
b. Instruments on a sterile field that is moist
c. Sterile items untouched by nonsterile items
d. Sterile pack opened out of sight line of the nurse
____ 14. The nurse is preparing to give a newly prescribed antibiotic to a patient with an infected surgical incision. Which action is essential for the nurse to do before giving the antibiotic?
a. Perform ordered cultures.
b. Check the patients temperature.
c. Give the patient something to eat.
d. Document the wounds appearance.
____ 15. The nurse is collecting data from a patient with a systemic infection. Which finding should the nurse expect in this patient?
a. Warm skin
b. Skin redness
c. General malaise
d. Purulent drainage
____ 16. The nurse is participating in planning care for a patient with mononucleosis. Which action should the nurse recommend to promote recovery?
a. Exercise
b. Rest periods
c. Full liquid diet
d. Fluid restriction
____ 17. The nurse is reinforcing teaching provided to a patient about gastrointestinal infections. Which symptom should the patient state which indicates that teaching has been effective?
a. Vomiting
b. Flank pain
c. Constipation
d. Cloudy urine
____ 18. The nurse is obtaining a health history from a patient who has a respiratory system infection. Which finding should the nurse identify as being the most significant?
a. Flank pain
b. Wheezing
c. Cramping
d. Anorexia
____ 19. The nurse is preparing to provide patient care. Which item is the most important for the nurse to wear if the possibility of handling body secretions exists?
a. Mask
b. Gown
c. Gloves
d. Goggles
____ 20. The nurse is preparing to care for a patient. For which action should the nurse use surgical asepsis to prevent infection?
a. Urinary catheter insertion
b. Taking a rectal temperature
c. Reinforcement of dressings
d. Irrigating a nasogastric tube
____ 21. The nurse is caring for a patient who has influenza. In which type of transmission-based precaution should the patient be placed?
a. Contact
b. Droplet
c. Airborne
d. Respiratory
____ 22. A patient requires care that might cause the splattering of body secretions. Which item should the nurse wear when caring for this patient?
a. Cap
b. Gown
c. Face shield
d. Shoe covers
____ 23. A patient voids and asks to have the urinal emptied. Which action should the nurse take first?
a. Empty the urinal.
b. Measure the urine.
c. Put on nonsterile gloves.
d. Offer patient hand hygiene.
____ 24. The nurse has contributed to a staff education program about the principles for the first tier of standard precautions. Which statement by a nursing assistant indicates a correct understanding of the teaching?
a. All patients are presumed infectious.
b. Isolation is not required for most diseases.
c. Patients with a known infection are placed in isolation upon admission.
d. Patients are not considered infectious until confirmed so by the laboratory.
____ 25. The nurse is contributing to a staff education program about infection control. What information from the following list should the nurse recommend including about methods that are effective in destroying bacterial spores?
a. Prolonged drying times
b. Prolonged high temperatures
c. Cleansing with soap and water
d. Brief exposure to room temperatures
____ 26. The nurse is contributing to a staff education program about infection control. Which information should the nurse recommend including as an example of a portal of exit for a pathogen in the chain of infection?
a. Hair
b. Nails
c. Mucous membranes
d. Central nervous system
____ 27. The nurse is caring for a patient with herpes simplex. Which statement related to disease transmission should the nurse include in the patients discharge teaching?
a. Herpes simplex is an airborne disease.
b. HEPA filtration is necessary with herpes simplex.
c. Herpes simplex is transmitted through direct transmission.
d. Vehicle transmission means that particles float through the air.
____ 28. The nurse observes a patient being transported through the hall wearing a mask. For which medical diagnosis should the nurse suspect the patient is receiving care?
a. Measles
b. Cellulitis
c. Diphtheria
d. Clostridium difficile
____ 29. The nurse is caring for a patient who is immunocompromised. Which action should the nurse take to ensure that the patient does not develop a hospital-acquired infection?
a. Restrict oral fluids
b. Apply lotion to dry skin
c. Provide alcohol-based mouthwash
d. Massage back with a skin drying agent
____ 30. A patient learns that a serum antibody test is positive. What should the nurse explain to the patient about this test result?
a. An active infection is present.
b. It is more accurate than a blood culture.
c. The body has been exposed to an antigen.
d. A specific antibiotic has been identified for the infection.
____ 31. The school nurse is planning to teach a group of school-age children on cough etiquette. What should the nurse emphasize with these students?
a. Sneeze into hands if a tissue is not available.
b. Place used tissues in back packs or pockets of clothing.
c. Wash hands with soap and water for 20 seconds after blowing the nose.
d. Move 1 foot away from another person when having to sneeze or cough.
Multiple Response
Identify one or more choices that best complete the statement or answer the question.

____ 32. The nurse is collecting data from a patient with a surgical incision. Which findings indicate to the nurse that a local infection is present? (Select all that apply.)
a. Fever
b. Redness
c. Swelling
d. Headache
e. Loss of appetite
f. General malaise
____ 33. The nurse suspects that patient is developing sepsis. Which findings did the nurse use to come to this conclusion? (Select all that apply.)
a. Tachycardia
b. Hypotension
c. Hypertension
d. Mental confusion
e. Increased capillary refill
f. Hyperactive bowel sounds
____ 34. The nurse is caring for a patient with tuberculosis. What airborne precautions should the nurse take while caring for this patient? (Select all that apply.)
a. Private patient room
b. Semiprivate patient room
c. Closed patient room door
d. Individualized respiratory mask
e. One-size-fits-all respiratory mask
____ 35. The nurse is caring for a patient who is in droplet precautions. The nurse must wear a mask when providing care within what distances of the patient? (Select all that apply.)
a. 1 foot
b. 2 feet
c. 3 feet
d. 4 feet
e. 5 feet
f. 6 feet
____ 36. The nurse is contributing to a staff education program about infection control. What should the nurse recommend as examples of diseases that are transmitted by direct contact? (Select all that apply.)
a. Malaria
b. Measles
c. Impetigo
d. Influenza
e. Chickenpox
f. Lyme disease
____ 37. A patient is being admitted for treatment of a viral infection. Which diseases should the nurse recognize as being caused by a virus? (Select all that apply.)
a. Measles
b. Shingles
c. Gonorrhea
d. Trichomoniasis
e. Candida albicans
f. Infectious mononucleosis
____ 38. A patient is being discharged from the hospital with a prescription for erythromycin. What should the nurse include when teaching about this medication? (Select all that apply.)
a. Avoid sun exposure.
b. Drowsiness may occur.
c. Take pills on an empty stomach.
d. Report vaginal irritation or white patches in the mouth.
e. Take with a full glass of water but not with an acidic juice.
f. Gastric distress may occur, but unless it is severe do not discontinue the medication.
____ 39. The nurse is providing care for a patient with a known allergy to sulfamethoxazole (Gantanol). Which medications should the nurse question if prescribed for this patient? (Select all that apply.)
a. Ciprofloxacin (Cipro)
b. Amoxicillin (Amoxil)
c. Levofloxacin (Levaquin)
d. Sulfisoxazole (Gantrisin)
e. Doxycycline (Vibramycin)
f. Trimethoprim sulfamethoxazole (Bactrim, Septra)
____ 40. A patient is admitted for treatment of an antibody-antigen response. What should the nurse explain to the patient about this response? (Select all that apply.)
a. Engulfs and digests the antigen
b. Initiates destruction of the antigen
c. Neutralizes toxins released by bacteria
d. Promotes antigen clumping with the antibody
e. Prevents the antigen from adhering to host cells
____ 41. The nurse is assisting with the development of an educational program to reduce the incidence of infectious diseases in a community. What topics should the nurse suggest be included in this program? (Select all that apply.)
a. Use of cough etiquette
b. Performance of hand hygiene
c. Safe food handling techniques
d. Use of safety equipment with sports
e. Importance of receiving immunizations

Chapter 8. Nursing Care of Patients With Infections
Answer Section

MULTIPLE CHOICE

1. ANS: D
A culture is obtained and grown to identify the presence of pathogens. B. C. A sensitivity examination is done after a culture, which exposes any organism to many antibiotics to determine which antibiotic will be most effective for treatment. A. A peak and trough level determines the level of an antibiotic present in the blood.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

2. ANS: C
Vector-borne transmission is the spread of infectious organisms through a living source other than humans. Rocky Mountain spotted fever is transmitted to humans by tick bite. A. Droplet transmission is a spray into the eyes or mucous membranes during sneezing, coughing, spitting, singing, or talking. D. Vehicle-borne transmission is the spread of an infectious organism by contact with a contaminated object. B. Airborne transmission occurs from organisms inhaled or deposited on the mucous membrane of a susceptible host.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application

3. ANS: D
Factors that increase susceptibility to infection are very young age, old age, malnourishment, being immunocompromised, chronic disease, stress, and invasive procedures. A. B. C. Although all individuals are encouraged to receive an annual influenza vaccination the 15-year-old, 26-year-old, and 49-year-old have more competent immune systems. The influenza vaccination can be delayed for these individuals.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Analysis

4. ANS: B
Vehicle-borne transmission is the spread of an infectious organism by contact with a contaminated object, such as dressings from a wound; surgical instruments; water, food, and biological products such as blood, serum, plasma, tissues, and organs. Conjunctivitis is a vehicle-borne illness. A, D. Droplet transmission is a spray into the eyes or mucous membranes and requires the use of a mask or a 3-foot distance between individuals. C. Airborne transmission occurs from organisms inhaled or deposited on the mucous membrane of a susceptible host.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Evaluation

5. ANS: C
Although using gloves, gowns, masks, goggles, and face shields help prevent the spread of infection, the most important action is hand washing.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application

6. ANS: D
Factors that increase susceptibility to infection are very young age, old age, malnourishment, immunocompromised, chronic disease, stress, and invasive procedures. Ensuring adequate nutrition for the hospitalized patient will help prevent infection. B. Daily bathing will not reduce the risk for contracting an infectious disease. C. Assessing vital signs every 4 hours will not reduce the risk for contracting an infectious disease. D. Placing the patient in a private room will not reduce the risk for contracting an infectious disease.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application

7. ANS: B
Fluid thins respiratory secretions to facilitate the removal through coughing. A. Fluids will not decrease metabolism. C. D. Influenza is caused by a virus. The patient will not have bacterial serum or urinary concentration.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

8. ANS: A
Manifestations of a local infection also include pain, redness, swelling, and warmth at the site. B. D. As the infection progresses, there can be an increase in fever, elevated white blood cell count, decreased blood pressure, mental confusion, tachycardia, and shock. C. Symptoms of generalized infection may include headache, malaise, muscle aches, fever, and anorexia.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Analysis

9. ANS: D
Staphylococcus aureus is the most common pathogen causing hospital-acquired surgical wound infections. A. B. C. Hospital-acquired surgical wound infections are not commonly caused by shigella, salmonella, or campylobacter.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Analysis

10. ANS: C
Symptoms of a urinary tract infection include urgency, frequency, burning, flank pain, change in color of urine, foul odor, discharge, or confusion or change in mental status. A. B. D. Diarrhea, vomiting, and abdominal distention are not manifestations of a urinary tract infection.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Analysis

11. ANS: C
A patient who is immobile is at increased risk for atelectasis and pneumonia. Encourage coughing and deep breathing to keep airways clear and prevent atelectasis. A. Fluid intake may be increased if the patient is at risk for fat emboli or renal calculi, but it is not the highest priority over oxygenation. B. Daily weights indicate fluid and nutritional status but are not the priority for this patient because there is no indication of an increased risk for dehydration, fluid overload, or malnutrition. D. Teaching the patient to cover the mouth when coughing prevents the spread of contagious disease and is not the priority for this patient.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Analysis

12. ANS: D
The nurse should wear a personally fit-tested high-efficiency particulate air respirator mask for airborne protection. A. B. Do not use other masks because they do not provide adequate airborne protection against TB. C. Eye goggles are not needed when caring for a patient with tuberculosis.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application

13. ANS: C
Surgical asepsis refers to an item or area that is free of all microorganisms and spores. Surgical asepsis is used in surgery and to sterilize equipment. Items can be subjected to intense heat or chemical disinfectants to destroy all organisms. Articles can be subjected to intense heat or chemical disinfectants. Once these articles are sterilized, they are dated, packaged, and sealed. A. Once a package is opened or outdated, it is no longer considered sterile. B. Moist areas are not sterile. D. Sterile packages should be opened in view of the nurse to verify they remain sterile.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application

14. ANS: A
Cultures are a priority to obtain before giving anti-infectives so the results are not altered by the medication. B. D. Checking the patients temperature and documenting the appearance of the wound do not need to be done before administering medication. C. Giving the antibiotic with food depends on the specific medication.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

15. ANS: C
Symptoms of systemic infection may include headache, malaise, muscle aches, fever, and anorexia. A. B. Manifestations of a local infection also include pain, redness, swelling, and warmth at the site. D. Purulent drainage occurs from the local inflammatory process.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Analysis

16. ANS: B
Symptoms of mononucleosis are treated as needed with supportive care. Fatigue may last for months. Rest is important. A. Exercise should be guided by the health care provider when the acute phase is over, based on patient tolerance. C. D. Fluids and diet are not restricted.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityBasic Care and Comfort | Cognitive Level: Application

17. ANS: A
The symptoms of gastrointestinal tract infections may include nausea, vomiting, diarrhea, cramping, and anorexia. Patients may have frequent episodes of emesis and diarrhea and need to be monitored for signs of dehydration resulting from the loss of fluid. B. D. Flank pain or cloudy urine may indicate a urinary tract or kidney infection. C. Constipation is not a manifestation of a gastrointestinal tract infection.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Evaluation

18. ANS: B
Lung sounds can include crackles, rhonchi, or wheezing in a patient with a respiratory system infection and can indicate potential respiratory distress. A, C, and D are not directly linked to the respiratory system and therefore are not the most significant finding.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

19. ANS: C
The use of gloves decreases the transmission of organisms and should be used whenever handling secretions. A. B. D. Gowns, masks, and protective eyewear may also be helpful in preventing transmission of organisms and are considered based on the situation and potential for exposure to organisms.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application

20. ANS: A
Surgical asepsis (sterile technique) refers to an item or area that is free of all microorganisms and spores. The urinary tract is a sterile system, and surgical asepsis must be used for urinary catheter insertion to maintain this sterility. B, C, and D are not actions requiring sterility.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application

21. ANS: B
Droplet precautions are needed for influenza. A. C. D. Influenza is transmitted through droplets. Contact, airborne, or respiratory precautions are not appropriate for this health problem.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application

22. ANS: C
Using a mask, eye protection, or face shield for patient care if splashes or sprays of blood or body fluids are likely is the most essential item to wear. A. B. D. A cap, gown, or shoe covers may be worn as needed.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application

23. ANS: C
The nurse would first put on gloves for protection, which do not need to be sterile to empty the urinal. B. A. Next, the nurse would measure the urine and then empty the urinal. D. The patient should be offered hand hygiene equipment to perform hand hygiene after voiding.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application

24. ANS: A
Standard precautions are used in the care of all patients. These precautions require one to assume that all patients are infectious regardless of their diagnosis. Using gloves, gowns, masks, goggles, face shields, and, most important, hand washing helps prevent the spread of infection to health care workers and other patients. B. C. D. Transmission-based precautions are only added as needed, such as isolation.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Analysis

25. ANS: B
Prolonged exposure to high temperature destroys spores. A. C. D. Prolonged drying times, cleaning with soap and water, or exposure to room temperatures are not effective to eliminate spores.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application

26. ANS: C
The portal of exit is the route by which the infectious agent leaves the host, which has become a reservoir for infection: respiratory tract, skin, mucous membranes, gastrointestinal tract, genitourinary tract, blood, open lesions, or placenta. A. B. D. Hair, nails, and the central nervous system are not portals of exit.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application

27. ANS: C
Herpes simplex is transmitted through direct transmission. Illnesses spread by direct transmission may include influenza, impetigo, scabies, conjunctivitis, pediculosis, herpes, Clostridium difficile, and all sexually transmitted diseases, including HIV. A. Measles, chickenpox, and tuberculosis are transmitted by airborne transmission. B. HEPA filtration is not required, because herpes simplex is not an airborne illness. D. Vehicle transmission refers to the spread of an infectious organism by contact with a contaminated object.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application

28. ANS: A
A mask must be worn for measles, tuberculosis, and varicella (chickenpox, shingles) during patient transport. B. C. D. A mask does not need to be worn for cellulitis, diphtheria, or clostridium difficile.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Analysis

29. ANS: B
Intact skin and mucous membranes are the bodys first line of defense against infection. Preventing skin dryness and cracking with lotion keeps the skin intact so organisms do not have an entry point. A. Restricting oral fluids could cause the oral mucous membranes to dry, permitting the entry of microorganisms into the body. C. Alcohol-based mouth washes are drying and could permit the entry of microorganisms into the body. D. Using a drying agent on the skin could encourage drying and cracking which could lead to microorganisms entering the body.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

30. ANS: C
A serum antibody test measures the reaction to a certain antigen. A. A positive result for this test does not always mean an active infection is present. It can simply mean there has been an exposure to the antigen. B. This test is not as accurate as a culture. D. This test does not identify antibiotics appropriate to treat an infection.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

31. ANS: C
The nurse should instruct the students to wash hands frequently with soap and water for 20 seconds especially after blowing the nose. A. Sneezing should be into the upper sleeve and not the hands. B. Used tissues should be placed in the waste basket. D. For droplet precautions, the distance is 3 feet so the students should be instructed to move at least 3 feet away from another person when sneezing.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

MULTIPLE RESPONSE

32. ANS: B, C
Manifestations of a local infection also include pain, redness, swelling, and warmth at the site. A. D. E. F. Symptoms of generalized infection may include headache, malaise, muscle aches, fever, and anorexia.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Analysis

33. ANS: A, B, C, D
There can be an increase in fever, elevated white blood cell count, decreased blood pressure, mental confusion, tachycardia, and shock with sepsis. E. F. Bowel sounds and capillary refill would be decreased.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

34. ANS: A, C, D
When caring for patients with tuberculosis, wear an individually fit-tested N95 or HEPA respirator. HEPA respirators filter the tiniest particles from the air, unlike surgical masks, which can allow such particles to pass into the respiratory system of a host. The patient must be in a private isolation room with the door closed. The mask must be individually fitted to ensure adequate protection. B. A private room is required. E. A one-size-fits-all respiratory mask is not adequate when caring for a patient with tuberculosis.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application

35. ANS: A, B, C
Direct transmission occurs through droplet spray into the eyes or mucous membranes during sneezing, coughing, spitting, singing, or talking. D. E. F. Droplet spread is usually limited to 3 feet or less.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application

36. ANS: A, C
Illnesses spread by direct transmission may include influenza, impetigo, scabies, conjunctivitis, pediculosis, herpes, C. difficile, and all sexually transmitted diseases, including HIV. B. E. Measles and chickenpox are transmitted by airborne transmission. A. F. Diseases spread through vectors include malaria and Lyme disease.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application

37. ANS: A, B, F
Shingles (varicella zoster), measles (rubeola), and infectious mononucleosis (Epstein-Barr) are caused by viruses. C. Gonorrhea (Neisseria gonorrhoeae) is caused by bacteria. D. Trichomoniasis (Trichomonas vaginalis) is caused by protozoa. E. Candida albicans is a fungus.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Analysis

38. ANS: C, E, F
Take on an empty stomach 1 hour before or 2 hours after meals. Take with a full glass of water and not with acidic fruit juices. Explain that gastric distress is common but not a reason to stop the drug. B. Fluoroquinolones may cause drowsiness. D. Penicillins may cause white patches in the mouth or vaginal irritation. A. Several other types of anti-infectives, such as sulfonamides or tetracycline, require avoidance of sun exposure.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

39. ANS: D, F
Patients with a known allergy to one antibiotic in a class should not be given other antibiotics in that same class due to potential allergy; Gantrisin, Bactrim, and Septra are sulfa antibiotics and should not be given to a patient with a sulfa allergy. A. B. C. E. These medications are not sulfa antibiotics and can safely be provided to the patient.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

40. ANS: B, C, D, E
Antibodies combine with specific foreign antigens on the surface of the invading organisms, such as bacteria or viruses, to control or destroy them. Antigens are neutralized or destroyed by antibodies by initiating destruction of the antigen; neutralizing toxins released by bacteria, promoting antigen clumping with the antibody, or preventing the antigen from adhering to host cells. A. Neutrophils and macrophages engulf and digest foreign antigens through phagocytosis.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

41. ANS: A, B, C, E
Educating the public about the importance of hand hygiene, the Center for Disease Control and Preventions (CDCs) respiratory hygiene/cough etiquette measures, immunization, clean water, safe food handling techniques, and safer sex precautions helps prevent the spread of disease in the community. D. Use of safety equipment with sports helps prevent accidental injuries.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

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