Concept 22: Infection My Nursing Test Banks

Concept 22: Infection

Test Bank

MULTIPLE CHOICE

1. The nurse is working on a plan of care with her patient which includes turning and positioning and adequate nutrition to help the patient maintain intact skin integrity. The nurse helps the patient to realize that this breaks the chain of infection by eliminating a

a.

host.

b.

mode of transmission.

c.

portal of entry.

d.

reservoir.

ANS: C

Broken or impaired skin creates a portal of entry for pathogens. By maintaining intact tissue, the patient and the nurse have broken the chain of infection by eliminating a portal of entry. Host is incorrect because you are not eliminating the person or organism. Intact tissue does not eliminate the mode of transmission. Skin can still be used to transfer pathogens regardless of it being intact or broken. Intact skin does not eliminate the location for pathogens to live and grow.

REF: 230

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

2. While reviewing the complete blood count (CBC) of a patient on her unit, the nurse notes elevated basophil and eosinophil readings. The nurse realizes that this is most indicative of a _____ infection.

a.

bacterial

b.

fungal

c.

parasitic

d.

viral

ANS: C

Parasitic infections are frequently indicated on a CBC by elevated basophil and eosinophil levels. Bacterial infections do not lead to elevated basophil and eosinophil levels but elevated B and T lymphocytes, neutrophils, and monocytes. Fungal infections do not lead to elevated basophil and eosinophil levels. Viral infections create elevations in B and T lymphocytes, neutrophils, and monocytes.

REF: 233

OBJ: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

3. Which set of assessment data is consistent for a patient with severe infection that could lead to system failure?

a.

Blood pressure (BP) 92/52, pulse (P) 56 beats/min, respiratory rate (RR) 10 breaths/min, urine output 1200 mL in past 24 hours

b.

BP 90/48, P 112 beats/min, RR 26 breaths/min, urine output 240 mL in past 24 hours

c.

BP 112/64, P 98 beats/min, RR 18 breaths/min, urine output 2400 mL in past 24 hours

d.

BP 152/90, P 52 beats/min, RR 12 breaths/min, urine output 4800 mL in past 24 hours

ANS: B

The patient with severe infection presents with low BP and compensating elevations in pulse to move lower volumes of blood more rapidly and respiration to increase access to oxygen. Urine output decreases to counteract the decreased circulating blood volume and hypotension. These vital signs are all too low: Blood pressure (BP) 92/52, pulse (P) 56 beats/min, respiratory rate (RR) 10 breaths/min, urine output 1200 mL in past 24 hours. The patient with severe infection does have a low BP, but the pulse and respiratory rate increase to compensate. This data is all within normal limits: BP 112/64, P 98 beats/min, RR 18 breaths/min, urine output 2400 mL in past 24 hours. This set of data reflects an elevated BP with a decrease in pulse and respiratory rates along with normal urine output: BP 152/90, P 52 beats/min, RR 12 breaths/min, urine output 4800 mL in past 24 hours. None of these is a typical response to severe infection.

REF: 231

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. A nurse is teaching a group of businesspeople about disease transmission. He knows that he needs to reeducate when one of the participants states which of the following?

a.

When traveling outside of the country, I need to be sure that I receive appropriate vaccinations.

b.

Food and water supplies in foreign countries can contain microorganisms to which my body is not accustomed and has no resistance.

c.

If I dont feel sick, then I dont have to worry about transmitted diseases.

d.

I need to be sure to have good hygiene practices when traveling in crowded planes and trains.

ANS: C

People can transmit pathogens even if they dont currently feel ill. Some carriers never experience the full symptoms of a pathogen. Travelers may need different vaccinations when traveling to countries outside their own because of variations in prevalent microorganisms. Food and water supplies in foreign countries can contain microorganisms that will affect a body unaccustomed to their presence. Adequate hygiene is essential when in crowded, public spaces like planes and other forms of public transportation.

REF: 227 OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

5. In order to provide the best intervention for a patient, the nurse is often responsible for obtaining a sample of exudate for culture. This test will identify

a.

whether a patient has an infection.

b.

where an infection is located.

c.

what cells are being utilized by the body to attack an infection.

d.

what specific type of pathogen is causing an infection.

ANS: D

People can transmit pathogens even if they dont currently feel ill. Some carriers never experience the full symptoms of a pathogen. A CBC will identify that the patient has an infection. Inspection and radiography will help identify where an infection is located. The CBC with differential will identify the white blood cells being used by the body to fight an infection. The culture will grow the microorganisms in the sample for identification of the specific type of pathogen.

REF: 233

OBJ: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

MULTIPLE RESPONSE

1. The nurse is caring for a patient with a diagnosed case of Clostridium difficile. The nurse expects to implement which of the following interventions? (Select all that apply.)

a.

Administration of protease inhibitors

b.

Use of personal protective equipment

c.

Patient teaching on methods to inhibit transmission

d.

Preventing visitors from entering the room

e.

Administration of intravenous fluids

f.

Strict monitoring of intake and output

ANS: B, C, E, F

Protease inhibitors are used for treatment of viral infections, not bacterial infections. The nurse wants to protect visitors from exposure to the bacteria and protect the patient from secondary infection while immunocompromised, but the patient will need the support of family and close friends. Contact isolation precautions must be strictly followed along with the use of personal protective equipment and teaching on methods to inhibit transmission to help break the chain of infection. Intravenous fluids and strict intake and output monitoring will be important for the patient suffering the effects of Clostridium difficile, because it causes diarrhea with fluid loss.

REF: 234-235

OBJ: NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort and Physiological Adaptation

2. Individuals of low socioeconomic status are at an increased risk for infection because of which of the following? (Select all that apply.)

a.

Uninsured or underinsured status

b.

Easy access to health screenings

c.

High cost of medications

d.

Inadequate nutrition

ANS: A, C, D

Individuals of low socioeconomic status tend to be part of the underinsured or uninsured population. Lack of insurance decreases accessibility to health care in general and health screening services specifically. High costs of medication and nutritious food also make this population at higher risk for infection.

REF: 229

OBJ: NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort and Psychosocial Integrity

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