Question 1
Regular
The nurse has admitted a new client to the unit. This client has an open draining sore on the leg. What diagnostic test would the nurse anticipate being ordered?
Correct!
Incorrect
The correct answer is: B
Rationale
Culture and sensitivity. This test is essential for identifying the specific pathogens causing the infection in the open draining sore, allowing for appropriate antibiotic therapy and management of the client’s condition.
A: Platelet count. This test measures the number of platelets in the blood and is not relevant to diagnosing infections in open sores.
C: Sputum culture. This diagnostic test evaluates respiratory secretions and is unrelated to wounds or leg infections, making it unsuitable for this client’s condition.
D: Urinalysis. This test assesses urine for signs of urinary tract issues and does not provide information about infections associated with an open sore on the leg.
Correct Answer: B
Rationale: Culture and sensitivity. This test is essential for identifying the specific pathogens causing the infection in the open draining sore, allowing for appropriate antibiotic therapy and management of the client’s condition.
A: Platelet count. This test measures the number of platelets in the blood and is not relevant to diagnosing infections in open sores.
C: Sputum culture. This diagnostic test evaluates respiratory secretions and is unrelated to wounds or leg infections, making it unsuitable for this client’s condition.
D: Urinalysis. This test assesses urine for signs of urinary tract issues and does not provide information about infections associated with an open sore on the leg.
Question 2
Regular
The nurse is caring for a client with a stage IV leg ulcer. The nurse is closely monitoring the client for sepsis. What would indicate that sepsis has occurred and that the nurse should notify the physician of immediately?
Correct!
Incorrect
The correct answer is: C
Rationale
The client's heart rate is greater than 90 beats/minute. Elevated heart rate is a classic sign of sepsis, indicating systemic infection and the body's heightened response, necessitating immediate medical intervention to prevent further complications.
A: The client feels restless and hungry. Restlessness may indicate discomfort or anxiety but does not specifically signify sepsis or an urgent need for medical evaluation in this context.
B: The client exhibits an increased urinary output. Increased urinary output can suggest good hydration or renal function, which does not correlate with the critical signs of sepsis that require immediate physician notification.
D: The client's respiratory rate is less than 20 breaths/minute. A respiratory rate below 20 is generally normal; hence, it does not reflect the urgency associated with potential sepsis in this clinical scenario.
Correct Answer: C
Rationale: The client's heart rate is greater than 90 beats/minute. Elevated heart rate is a classic sign of sepsis, indicating systemic infection and the body's heightened response, necessitating immediate medical intervention to prevent further complications.
A: The client feels restless and hungry. Restlessness may indicate discomfort or anxiety but does not specifically signify sepsis or an urgent need for medical evaluation in this context.
B: The client exhibits an increased urinary output. Increased urinary output can suggest good hydration or renal function, which does not correlate with the critical signs of sepsis that require immediate physician notification.
D: The client's respiratory rate is less than 20 breaths/minute. A respiratory rate below 20 is generally normal; hence, it does not reflect the urgency associated with potential sepsis in this clinical scenario.
Question 3
Regular
The nurse is giving an educational talk to a local parent-teacher association. A parent asks how to help the family avoid community-acquired infections. What would be the nurse's best response to help prevent and control community-acquired infections?
Correct!
Incorrect
The correct answer is: C
Rationale
Make sure your family has all their childhood immunizations. Ensuring that families are up to date with vaccinations is crucial in preventing the spread of community-acquired infections, as immunizations provide essential protection against various contagious diseases.
A: Encourage your family to adopt a healthy diet and exercise regimen. While a healthy lifestyle supports overall well-being, it does not directly target the prevention of infections in the community.
B: Encourage your family to stop smoking. Quitting smoking may improve health and immunity but does not specifically address the prevention of community-acquired infections or their transmission.
D: Make sure your family has regular check-ups. Regular check-ups help monitor health but do not actively prevent infections, which requires proactive measures like vaccinations to be effective.
Correct Answer: C
Rationale: Make sure your family has all their childhood immunizations. Ensuring that families are up to date with vaccinations is crucial in preventing the spread of community-acquired infections, as immunizations provide essential protection against various contagious diseases.
A: Encourage your family to adopt a healthy diet and exercise regimen. While a healthy lifestyle supports overall well-being, it does not directly target the prevention of infections in the community.
B: Encourage your family to stop smoking. Quitting smoking may improve health and immunity but does not specifically address the prevention of community-acquired infections or their transmission.
D: Make sure your family has regular check-ups. Regular check-ups help monitor health but do not actively prevent infections, which requires proactive measures like vaccinations to be effective.
Question 4
Regular
The nurse is teaching a health class in the local public health center. What instructions should the nurse provide as the single most important measure to prevent the spread of infection?
Correct!
Incorrect
The correct answer is: C
Rationale
Thorough handwashing. This practice effectively removes pathogens from hands, significantly reducing the transmission of infections in public health settings. It is a fundamental preventive measure supported by health guidelines and research.
A: Minimal social contact. While reducing social interaction can help lower infection rates, it is not the most effective method for preventing the spread of pathogens directly.
B: Regular immunizations. Immunizations play a vital role in preventing certain diseases, but they do not address the immediate and widespread transmission of infections that handwashing mitigates.
D: Sufficient food intake. Adequate nutrition is essential for overall health but does not directly influence the prevention of infection spread, which primarily relies on hygiene practices.
Correct Answer: C
Rationale: Thorough handwashing. This practice effectively removes pathogens from hands, significantly reducing the transmission of infections in public health settings. It is a fundamental preventive measure supported by health guidelines and research.
A: Minimal social contact. While reducing social interaction can help lower infection rates, it is not the most effective method for preventing the spread of pathogens directly.
B: Regular immunizations. Immunizations play a vital role in preventing certain diseases, but they do not address the immediate and widespread transmission of infections that handwashing mitigates.
D: Sufficient food intake. Adequate nutrition is essential for overall health but does not directly influence the prevention of infection spread, which primarily relies on hygiene practices.
Question 5
Regular
A nurse on the unit sustains a needlestick injury while caring for a client whose infectious status is unknown. What would be the best course of action for the nurse to follow?
Correct!
Incorrect
The correct answer is: C
Rationale
Be tested for disease antibodies at appropriate intervals. This action ensures the nurse monitors for potential infections from the needlestick and can take necessary precautions or treatments promptly, safeguarding their health.
A: Avoid notifying the supervisor of the injury until the client's infectious status is confirmed. Failing to notify the supervisor delays essential assessments and interventions, potentially compromising the nurse's health and workplace safety.
B: Avoid revealing the identity of the client or source of blood. While maintaining confidentiality is vital, addressing the needlestick injury takes precedence to ensure timely medical evaluation and care for the nurse.
D: Document the injury in writing after the client's infectious status is confirmed. Delaying documentation could lead to loss of critical information and impede proper follow-up and response to the injury.
Correct Answer: C
Rationale: Be tested for disease antibodies at appropriate intervals. This action ensures the nurse monitors for potential infections from the needlestick and can take necessary precautions or treatments promptly, safeguarding their health.
A: Avoid notifying the supervisor of the injury until the client's infectious status is confirmed. Failing to notify the supervisor delays essential assessments and interventions, potentially compromising the nurse's health and workplace safety.
B: Avoid revealing the identity of the client or source of blood. While maintaining confidentiality is vital, addressing the needlestick injury takes precedence to ensure timely medical evaluation and care for the nurse.
D: Document the injury in writing after the client's infectious status is confirmed. Delaying documentation could lead to loss of critical information and impede proper follow-up and response to the injury.
Question 6
Regular
The nursing instructor is teaching beginning nursing students about infection. Toward the end of class, the instructor gives the students a scenario of a client with an infection who has developed fever and diarrhea. What should the student nurse instruct the client to avoid?
Correct!
Incorrect
The correct answer is: A
Rationale
Avoiding tea and coffee is advisable for the client with an infection, fever, and diarrhea as these beverages can be dehydrating and may exacerbate gastrointestinal symptoms, complicating recovery.
B: Ice water and broth provide hydration and essential nutrients, which are beneficial for someone recovering from fever and diarrhea, making them suitable for consumption.
C: Fruit juices can offer hydration and vitamins, helping replenish lost nutrients during illness, thus making them a supportive option rather than something to avoid.
D: Milk and gelatin can be gentle on the stomach and provide calories, which may assist in maintaining energy levels during recovery from an infection.
Correct Answer: A
Rationale: Avoiding tea and coffee is advisable for the client with an infection, fever, and diarrhea as these beverages can be dehydrating and may exacerbate gastrointestinal symptoms, complicating recovery.
B: Ice water and broth provide hydration and essential nutrients, which are beneficial for someone recovering from fever and diarrhea, making them suitable for consumption.
C: Fruit juices can offer hydration and vitamins, helping replenish lost nutrients during illness, thus making them a supportive option rather than something to avoid.
D: Milk and gelatin can be gentle on the stomach and provide calories, which may assist in maintaining energy levels during recovery from an infection.
Question 7
Regular
The nurse is working on a gerontology unit. A family member calls and tells the nurse they want to bring the family in to see one of the clients on the unit. The family member is concerned because several of the family members have colds. What instructions should the nurse provide to someone with a respiratory infection?
Correct!
Incorrect
The correct answer is: B
Rationale
B: Avoid visiting older adults. Individuals with respiratory infections pose a significant risk to older adults, who often have weakened immune systems. The nurse should prioritize the health of vulnerable patients by advising against visits until the family member recovers.
A: Avoid intake of frozen foods. This option does not relate to the transmission of respiratory infections and does not address the immediate concern of protecting older adults' health.
C: Avoid direct sunlight. Exposure to sunlight has no relevance to respiratory infections and does not contribute to the prevention of illness transmission in older adults.
D: Avoid meats and other protein-rich foods. Dietary choices do not influence the spread of respiratory infections and are not pertinent to the context of visiting someone with health vulnerabilities.
Correct Answer: B
Rationale: B: Avoid visiting older adults. Individuals with respiratory infections pose a significant risk to older adults, who often have weakened immune systems. The nurse should prioritize the health of vulnerable patients by advising against visits until the family member recovers.
A: Avoid intake of frozen foods. This option does not relate to the transmission of respiratory infections and does not address the immediate concern of protecting older adults' health.
C: Avoid direct sunlight. Exposure to sunlight has no relevance to respiratory infections and does not contribute to the prevention of illness transmission in older adults.
D: Avoid meats and other protein-rich foods. Dietary choices do not influence the spread of respiratory infections and are not pertinent to the context of visiting someone with health vulnerabilities.
Question 8
Regular
The intensive care unit nurse is caring for a client with a transmissible spongiform encephalopathy. The nurse knows that this type of encephalopathy is caused by what type of infectious agent?
Correct!
Incorrect
The correct answer is: A
Rationale
Prion. Transmissible spongiform encephalopathies are neurodegenerative diseases caused by prions, which are misfolded proteins that induce abnormal folding of normal proteins in the brain, leading to severe neurological damage.
B: Protozoa. Protozoa are single-celled organisms, often associated with infections, but they do not cause transmissible spongiform encephalopathies, which are specifically linked to prion-related mechanisms.
C: Helminth. Helminths are parasitic worms that cause a variety of diseases, yet they are unrelated to the protein misfolding processes characteristic of transmissible spongiform encephalopathies.
D: Rickettsia. Rickettsia are bacteria that typically cause infections through vector transmission, distinct from the prion-induced pathology seen in transmissible spongiform encephalopathies.
Correct Answer: A
Rationale: Prion. Transmissible spongiform encephalopathies are neurodegenerative diseases caused by prions, which are misfolded proteins that induce abnormal folding of normal proteins in the brain, leading to severe neurological damage.
B: Protozoa. Protozoa are single-celled organisms, often associated with infections, but they do not cause transmissible spongiform encephalopathies, which are specifically linked to prion-related mechanisms.
C: Helminth. Helminths are parasitic worms that cause a variety of diseases, yet they are unrelated to the protein misfolding processes characteristic of transmissible spongiform encephalopathies.
D: Rickettsia. Rickettsia are bacteria that typically cause infections through vector transmission, distinct from the prion-induced pathology seen in transmissible spongiform encephalopathies.
Question 9
Regular
Which of the following would be considered a mechanical defense mechanism?
Correct!
Incorrect
The correct answer is: B
Rationale
Coughing serves as a mechanical defense mechanism by expelling foreign particles and irritants from the respiratory tract, thereby protecting the body from potential harm and maintaining respiratory health.
A: Cast Immobilizes a broken bone but does not actively defend against pathogens or external threats, thus lacking the dynamic protective function characteristic of mechanical defense mechanisms.
C: Clothing provides a barrier to the skin, yet its primary role is not actively defending against intruders, making it less effective as a mechanical defense mechanism.
D: Sunscreen acts as a chemical barrier against UV radiation rather than a mechanical defense, failing to physically obstruct or remove harmful agents from the skin’s surface.
Correct Answer: B
Rationale: Coughing serves as a mechanical defense mechanism by expelling foreign particles and irritants from the respiratory tract, thereby protecting the body from potential harm and maintaining respiratory health.
A: Cast Immobilizes a broken bone but does not actively defend against pathogens or external threats, thus lacking the dynamic protective function characteristic of mechanical defense mechanisms.
C: Clothing provides a barrier to the skin, yet its primary role is not actively defending against intruders, making it less effective as a mechanical defense mechanism.
D: Sunscreen acts as a chemical barrier against UV radiation rather than a mechanical defense, failing to physically obstruct or remove harmful agents from the skin’s surface.
Question 10
Regular
A client with a Staphylococcus aureus infection present in a sacral pressure ulcer has received treatment with three courses of antibiotics without eliminating the infection. What does the nurse understand has occurred with the client?
Correct!
Incorrect
The correct answer is: A
Rationale
The client has a multidrug-resistant strain of bacteria. Continuous antibiotic treatment failure suggests that the Staphylococcus aureus has developed resistance to the medications, complicating effective management of the infection and necessitating alternative therapeutic approaches.
B: The client has been misdiagnosed and has another type of microorganism present. The persistence of Staphylococcus aureus indicates that misdiagnosis is unlikely; the strain is simply resistant to current antibiotic therapies.
C: Staphylococcus aureus cannot be treated by antibiotics. This assertion overlooks that many strains of Staphylococcus aureus are treatable, but resistance can render certain antibiotics ineffective, requiring tailored treatment strategies.
D: Staphylococcus aureus is a fungus and must be treated with an antifungal agent, not an antibiotic. Staphylococcus aureus is a bacterium, not a fungus, hence antifungal treatments would be ineffective against this bacterial infection.
Correct Answer: A
Rationale: The client has a multidrug-resistant strain of bacteria. Continuous antibiotic treatment failure suggests that the Staphylococcus aureus has developed resistance to the medications, complicating effective management of the infection and necessitating alternative therapeutic approaches.
B: The client has been misdiagnosed and has another type of microorganism present. The persistence of Staphylococcus aureus indicates that misdiagnosis is unlikely; the strain is simply resistant to current antibiotic therapies.
C: Staphylococcus aureus cannot be treated by antibiotics. This assertion overlooks that many strains of Staphylococcus aureus are treatable, but resistance can render certain antibiotics ineffective, requiring tailored treatment strategies.
D: Staphylococcus aureus is a fungus and must be treated with an antifungal agent, not an antibiotic. Staphylococcus aureus is a bacterium, not a fungus, hence antifungal treatments would be ineffective against this bacterial infection.
Question 11
Regular
A client is diagnosed with a viral illness and requests an antibiotic to 'cure' the illness. When the request is refused by the physician, the client states to the nurse, 'I will never get better.' What is the best response by the nurse?
Correct!
Incorrect
The correct answer is: B
Rationale
Antibiotics are ineffective against viral infections, and prescribing them can lead to drug resistance, which poses a significant public health risk. Educating the client about this helps clarify misconceptions and promotes appropriate treatment practices.
A: I will speak with the physician again. You will only get better while taking an antibiotic. This response misleads the client by suggesting antibiotics are necessary for recovery from a viral illness.
C: You need to think positively, and you will get better soon. This response fails to address the client’s medical misunderstanding and relies solely on optimism rather than providing factual information.
D: Taking antibiotics when you don't need them will make you sick. While partially true, this statement does not acknowledge the client’s concerns and lacks the educational context regarding viral illnesses and antibiotic use.
Correct Answer: B
Rationale: Antibiotics are ineffective against viral infections, and prescribing them can lead to drug resistance, which poses a significant public health risk. Educating the client about this helps clarify misconceptions and promotes appropriate treatment practices.
A: I will speak with the physician again. You will only get better while taking an antibiotic. This response misleads the client by suggesting antibiotics are necessary for recovery from a viral illness.
C: You need to think positively, and you will get better soon. This response fails to address the client’s medical misunderstanding and relies solely on optimism rather than providing factual information.
D: Taking antibiotics when you don't need them will make you sick. While partially true, this statement does not acknowledge the client’s concerns and lacks the educational context regarding viral illnesses and antibiotic use.
Question 12
Regular
The infection control nurse collects data that indicates an increase in the number of clients in the hospital with multidrug-resistant infections. What priority education should healthcare providers receive?
Correct!
Incorrect
The correct answer is: C
Rationale
Performing hand hygiene. Hand hygiene is crucial in preventing the spread of multidrug-resistant infections, as it significantly reduces the transmission of pathogens within healthcare settings, protecting both patients and staff from infection.
A: Using contact precautions on all clients in the hospital. This approach could overwhelm resources and may not be necessary for all patients, potentially leading to non-compliance and gaps in care.
B: Administering antibiotics to all clients prophylactically. This practice risks contributing to antibiotic resistance and may expose patients to unnecessary side effects without addressing the specific infections present.
D: Emptying trash cans immediately in client's rooms. While cleanliness is important, this action does not directly impact the transmission of infections and distracts from more effective preventive measures like hand hygiene.
Correct Answer: C
Rationale: Performing hand hygiene. Hand hygiene is crucial in preventing the spread of multidrug-resistant infections, as it significantly reduces the transmission of pathogens within healthcare settings, protecting both patients and staff from infection.
A: Using contact precautions on all clients in the hospital. This approach could overwhelm resources and may not be necessary for all patients, potentially leading to non-compliance and gaps in care.
B: Administering antibiotics to all clients prophylactically. This practice risks contributing to antibiotic resistance and may expose patients to unnecessary side effects without addressing the specific infections present.
D: Emptying trash cans immediately in client's rooms. While cleanliness is important, this action does not directly impact the transmission of infections and distracts from more effective preventive measures like hand hygiene.
Question 13
Regular
A client visits the clinic reporting a circular rash on the upper right arm. The rash is diagnosed as tinea corporis. For what type of infection does the nurse anticipate the client will be treated?
Correct!
Incorrect
The correct answer is: D
Rationale
The client will be treated for a fungus.
Tinea corporis, commonly known as ringworm, is a fungal infection that manifests as a circular rash. Antifungal treatments are specifically designed to target and eliminate fungal pathogens, making them the appropriate choice for managing this condition effectively.
A: Rickettsiae Rickettsiae are bacteria transmitted by arthropod vectors, leading to entirely different infection types, such as typhus or spotted fever, not related to the identified fungal rash.
B: Protozoans Protozoans are single-celled organisms that typically cause infections like malaria or giardiasis, which do not correspond to the symptoms or diagnosis of tinea corporis.
C: Mycoplasma Mycoplasma are a type of bacteria that lack a cell wall and primarily cause respiratory infections, which are unrelated to skin fungal infections like tinea corporis.
Correct Answer: D
Rationale: The client will be treated for a fungus.
Tinea corporis, commonly known as ringworm, is a fungal infection that manifests as a circular rash. Antifungal treatments are specifically designed to target and eliminate fungal pathogens, making them the appropriate choice for managing this condition effectively.
A: Rickettsiae Rickettsiae are bacteria transmitted by arthropod vectors, leading to entirely different infection types, such as typhus or spotted fever, not related to the identified fungal rash.
B: Protozoans Protozoans are single-celled organisms that typically cause infections like malaria or giardiasis, which do not correspond to the symptoms or diagnosis of tinea corporis.
C: Mycoplasma Mycoplasma are a type of bacteria that lack a cell wall and primarily cause respiratory infections, which are unrelated to skin fungal infections like tinea corporis.
Question 14
Regular
A client has received a diagnosis of Lyme disease. What does the nurse understand about the transmission of infection resulting in this disease?
Correct!
Incorrect
The correct answer is: D
Rationale
D: The disease is spread by arthropods. Lyme disease is primarily transmitted to humans through the bite of infected black-legged ticks, which are classified as arthropods, confirming this option as accurate.
A: The disease is spread by a prion. Prions are misfolded proteins that cause neurodegenerative diseases, not infectious diseases like Lyme disease, which is transmitted through ticks.
B: The disease is spread by single-celled fungi-like microorganisms. Lyme disease is caused by the bacterium Borrelia burgdorferi and is not associated with fungi or their transmission.
C: The disease is spread by helminths. Helminths are parasitic worms and do not play a role in Lyme disease transmission, which relies on tick vectors for infection.
Correct Answer: D
Rationale: D: The disease is spread by arthropods. Lyme disease is primarily transmitted to humans through the bite of infected black-legged ticks, which are classified as arthropods, confirming this option as accurate.
A: The disease is spread by a prion. Prions are misfolded proteins that cause neurodegenerative diseases, not infectious diseases like Lyme disease, which is transmitted through ticks.
B: The disease is spread by single-celled fungi-like microorganisms. Lyme disease is caused by the bacterium Borrelia burgdorferi and is not associated with fungi or their transmission.
C: The disease is spread by helminths. Helminths are parasitic worms and do not play a role in Lyme disease transmission, which relies on tick vectors for infection.
Question 15
Regular
A family member wants to donate blood for a client who needs a blood transfusion. What information from the family member would make them ineligible for donation?
Correct!
Incorrect
The correct answer is: A
Rationale
A family member was serving in the military in England in 1993 for 2 years. This duration of military service during the specified time could potentially expose the donor to certain infections, making them ineligible.
B: The family member had a surgical procedure 4 years previously for an inguinal hernia. Surgical history alone, especially when healed and not recent, typically does not disqualify someone from donating blood.
C: The family member received a blood transfusion 10 years previously at a hospital in Canada. Blood transfusions can affect eligibility, but the time elapsed is sufficient for safety, allowing donation.
D: The family member takes an antihypertensive medication for control of blood pressure. Many individuals on antihypertensive medication can still donate blood, as long as their condition is stable and well-managed.
Correct Answer: A
Rationale: A family member was serving in the military in England in 1993 for 2 years. This duration of military service during the specified time could potentially expose the donor to certain infections, making them ineligible.
B: The family member had a surgical procedure 4 years previously for an inguinal hernia. Surgical history alone, especially when healed and not recent, typically does not disqualify someone from donating blood.
C: The family member received a blood transfusion 10 years previously at a hospital in Canada. Blood transfusions can affect eligibility, but the time elapsed is sufficient for safety, allowing donation.
D: The family member takes an antihypertensive medication for control of blood pressure. Many individuals on antihypertensive medication can still donate blood, as long as their condition is stable and well-managed.
Question 16
Regular
A family member of a client in a long-term care facility asks why the nurse cannot insert a catheter so the client will not develop skin breakdown from being wet. What should the explanation include when the nurse responds to the family member?
Correct!
Incorrect
The correct answer is: C
Rationale
Catheters can introduce bacteria into the urinary tract, increasing the risk of urinary tract infections, particularly in older adults with compromised health. Therefore, minimizing catheter use is crucial for preventing potential complications like infections.
A: Catheters are no longer used for treatment of incontinence. Catheters are still utilized in certain situations, but their use is carefully considered due to associated risks, especially in long-term care.
B: Older adult residents are able to have catheters inserted if the family requests them. Family requests do not override clinical guidelines; insertion requires medical necessity, considering the patient's overall health and risks.
D: If a catheter is inserted, it must be flushed with normal saline daily. While flushing may be necessary, this procedure alone does not address the risks associated with catheter use, such as infections.
Correct Answer: C
Rationale: Catheters can introduce bacteria into the urinary tract, increasing the risk of urinary tract infections, particularly in older adults with compromised health. Therefore, minimizing catheter use is crucial for preventing potential complications like infections.
A: Catheters are no longer used for treatment of incontinence. Catheters are still utilized in certain situations, but their use is carefully considered due to associated risks, especially in long-term care.
B: Older adult residents are able to have catheters inserted if the family requests them. Family requests do not override clinical guidelines; insertion requires medical necessity, considering the patient's overall health and risks.
D: If a catheter is inserted, it must be flushed with normal saline daily. While flushing may be necessary, this procedure alone does not address the risks associated with catheter use, such as infections.
Question 17
Regular
A client informs the nurse of having been using a douche to cleanse the vagina on a daily basis and is now experiencing itching and burning in the vaginal area. What should the nurse explain to the client that occurs when the vaginal pH is changed?
Correct!
Incorrect
The correct answer is: A
Rationale
It causes destruction of the normal flora of the vagina and allows the development of vaginal infections. Changing the vaginal pH disrupts the balance of beneficial microorganisms, making the area more susceptible to infections and irritation, which explains the client's symptoms of itching and burning.
B: The bottle must be contaminated with bacteria, and when the pH is changed, it allows the bacteria to enter the vaginal area. This scenario does not specifically address the direct effects of altered pH on vaginal flora.
C: It will cause an allergic reaction in the vaginal area. While allergic reactions can occur, they are not a direct result of pH changes affecting normal flora or infection susceptibility.
D: When the vaginal pH is changed, it allows cancer cells to spread from the vagina to the cervix. This option misrepresents the relationship between pH changes and cancer cell behavior, which is unrelated to the client’s symptoms.
Correct Answer: A
Rationale: It causes destruction of the normal flora of the vagina and allows the development of vaginal infections. Changing the vaginal pH disrupts the balance of beneficial microorganisms, making the area more susceptible to infections and irritation, which explains the client's symptoms of itching and burning.
B: The bottle must be contaminated with bacteria, and when the pH is changed, it allows the bacteria to enter the vaginal area. This scenario does not specifically address the direct effects of altered pH on vaginal flora.
C: It will cause an allergic reaction in the vaginal area. While allergic reactions can occur, they are not a direct result of pH changes affecting normal flora or infection susceptibility.
D: When the vaginal pH is changed, it allows cancer cells to spread from the vagina to the cervix. This option misrepresents the relationship between pH changes and cancer cell behavior, which is unrelated to the client’s symptoms.
Question 18
Regular
A client is admitted to an acute care facility with a diagnosis of appendicitis. Which laboratory results demonstrate the client's leukocytosis?
Correct!
Incorrect
The correct answer is: D
Rationale
A client with a white blood cell (WBC) count of 22,000 cells/mm demonstrates leukocytosis. This elevated count indicates an immune response, typical in appendicitis, reflecting infection or inflammation.
A: Hemoglobin of 12 mg/dL indicates anemia, unrelated to leukocytosis. It reflects the oxygen-carrying capacity of blood, not the white blood cell response to infection.
B: Lymphocytes 1,500 represent a normal count and do not indicate leukocytosis. This value pertains to a specific type of white blood cell, not the overall leukocyte increase.
C: Neutrophils of 3,150/mms suggest a possible response but are insufficient to define leukocytosis. This number, while elevated, does not surpass the threshold that indicates a significant increase in total leukocyte count.
Correct Answer: D
Rationale: A client with a white blood cell (WBC) count of 22,000 cells/mm demonstrates leukocytosis. This elevated count indicates an immune response, typical in appendicitis, reflecting infection or inflammation.
A: Hemoglobin of 12 mg/dL indicates anemia, unrelated to leukocytosis. It reflects the oxygen-carrying capacity of blood, not the white blood cell response to infection.
B: Lymphocytes 1,500 represent a normal count and do not indicate leukocytosis. This value pertains to a specific type of white blood cell, not the overall leukocyte increase.
C: Neutrophils of 3,150/mms suggest a possible response but are insufficient to define leukocytosis. This number, while elevated, does not surpass the threshold that indicates a significant increase in total leukocyte count.
Question 19
Regular
A client comes to the clinic and informs of having a 'painful area under my armpit.' The nurse observes a 2-cm raised area that is erythremic and has a white substance inside of it. What does the nurse suspect the client may be experiencing?
Correct!
Incorrect
The correct answer is: B
Rationale
An abscess. The presence of a 2-cm raised, erythremic area with a white substance strongly indicates an accumulation of pus, characteristic of an abscess, resulting from infection or inflammation in the tissue.
A: A lesion. While the raised area can be classified as a lesion, it lacks specific features suggesting malignancy or chronicity, distinguishing it from the indicative signs of an abscess.
C: A fluid-filled vesicle. The description does not align with a vesicle, as vesicles typically contain clear fluid, whereas this case features a white substance, suggestive of pus in an abscess.
D: A cancerous tumor. The characteristics presented do not support a cancer diagnosis, as tumors usually present as irregular masses without acute inflammation or pus formation, which is typical of an abscess.
Correct Answer: B
Rationale: An abscess. The presence of a 2-cm raised, erythremic area with a white substance strongly indicates an accumulation of pus, characteristic of an abscess, resulting from infection or inflammation in the tissue.
A: A lesion. While the raised area can be classified as a lesion, it lacks specific features suggesting malignancy or chronicity, distinguishing it from the indicative signs of an abscess.
C: A fluid-filled vesicle. The description does not align with a vesicle, as vesicles typically contain clear fluid, whereas this case features a white substance, suggestive of pus in an abscess.
D: A cancerous tumor. The characteristics presented do not support a cancer diagnosis, as tumors usually present as irregular masses without acute inflammation or pus formation, which is typical of an abscess.
Question 20
Regular
A client is admitted to the acute care facility for vomiting and diarrhea. An intravenous (IV) catheter is inserted for the delivery of IV fluids. A family member is with the client and observes the nurse enter the room and begin touching the IV site without washing hands or wearing gloves. Why should the client and family member be concerned with the nurse's actions?
Correct!
Incorrect
The correct answer is: C
Rationale
The client will develop a healthcare-associated infection. Touching the IV site without proper hand hygiene or gloves increases the risk of introducing pathogens, which can lead to serious infections during hospitalization.
A: The client will have an allergic reaction to the IV. Allergic reactions are specific to medications or materials, not primarily influenced by hand hygiene practices, making this scenario unlikely.
B: The nurse could develop the same symptoms. The nurse’s potential illness does not directly relate to the IV site contamination risk; the focus should be on the patient's safety.
D: Dislodging of the IV catheter. While dislodgment is a concern, the immediate risk posed by contamination and potential infection is far more critical in this situation.
Correct Answer: C
Rationale: The client will develop a healthcare-associated infection. Touching the IV site without proper hand hygiene or gloves increases the risk of introducing pathogens, which can lead to serious infections during hospitalization.
A: The client will have an allergic reaction to the IV. Allergic reactions are specific to medications or materials, not primarily influenced by hand hygiene practices, making this scenario unlikely.
B: The nurse could develop the same symptoms. The nurse’s potential illness does not directly relate to the IV site contamination risk; the focus should be on the patient's safety.
D: Dislodging of the IV catheter. While dislodgment is a concern, the immediate risk posed by contamination and potential infection is far more critical in this situation.
Question 21
Regular
A client arrives at the clinic reporting vaginal discharge after having sexual intercourse 1 week ago. The client is diagnosed with gonorrhea and given a prescription for treatment. What type of infection transmission does the nurse understand occurred?
Correct!
Incorrect
The correct answer is: A
Rationale
Direct Answer: The type of infection transmission that occurred is direct contact.
Correct Option Explanation: Gonorrhea is typically transmitted through direct sexual contact with an infected person. The client's report of vaginal discharge following intercourse indicates that the infection was likely acquired during this intimate interaction, which facilitates the spread of the bacteria.
B: Droplet Transmission involves respiratory particles transferring infections, not applicable in this case since gonorrhea is not spread through respiratory means.
C: Airborne Transmission requires pathogens to remain suspended in the air, which does not pertain to gonorrhea as it is not transmitted this way.
D: Vehicle Transmission involves contaminated substances, such as food or water, but gonorrhea transmission occurs primarily through direct sexual contact rather than through external vehicles.
Correct Answer: A
Rationale: Direct Answer: The type of infection transmission that occurred is direct contact.
Correct Option Explanation: Gonorrhea is typically transmitted through direct sexual contact with an infected person. The client's report of vaginal discharge following intercourse indicates that the infection was likely acquired during this intimate interaction, which facilitates the spread of the bacteria.
B: Droplet Transmission involves respiratory particles transferring infections, not applicable in this case since gonorrhea is not spread through respiratory means.
C: Airborne Transmission requires pathogens to remain suspended in the air, which does not pertain to gonorrhea as it is not transmitted this way.
D: Vehicle Transmission involves contaminated substances, such as food or water, but gonorrhea transmission occurs primarily through direct sexual contact rather than through external vehicles.
Question 22
Regular
A client arrives at the emergency department reporting severe diarrhea and vomiting that began after ingesting a hot dog at the ballpark 6 hours ago. How does the nurse understand that the contaminated food was transmitted to the client?
Correct!
Incorrect
The correct answer is: C
Rationale
C: Vehicle. Contaminated food can transmit pathogens through the consumption of food items, which aligns with the client's experience of severe gastrointestinal symptoms following hot dog ingestion. This mode of transmission highlights the role of food as a vehicle for infection.
A: Droplet. This transmission route involves respiratory particles, not relevant to gastrointestinal pathogens acquired through contaminated food. The client’s symptoms are unrelated to respiratory exposure.
B: Airborne. Pathogens that spread through the air are not associated with foodborne illnesses. The client’s condition directly follows food consumption, negating any airborne transmission plausibility.
D: Vector. Vectors are typically living organisms that transmit diseases, such as insects. In this case, the transmission method is clearly linked to the ingestion of contaminated food, not a vector.
Correct Answer: C
Rationale: C: Vehicle. Contaminated food can transmit pathogens through the consumption of food items, which aligns with the client's experience of severe gastrointestinal symptoms following hot dog ingestion. This mode of transmission highlights the role of food as a vehicle for infection.
A: Droplet. This transmission route involves respiratory particles, not relevant to gastrointestinal pathogens acquired through contaminated food. The client’s symptoms are unrelated to respiratory exposure.
B: Airborne. Pathogens that spread through the air are not associated with foodborne illnesses. The client’s condition directly follows food consumption, negating any airborne transmission plausibility.
D: Vector. Vectors are typically living organisms that transmit diseases, such as insects. In this case, the transmission method is clearly linked to the ingestion of contaminated food, not a vector.
Question 23
Regular
A client comes to the clinic reporting fever, chills, and coughing. The client is found to be positive for influenza. The nurse is aware that influenza is transmitted from one infected person to another. What type of infectious disorder is this considered?
Correct!
Incorrect
The correct answer is: C
Rationale
Communicable disease. Influenza spreads easily between individuals through respiratory droplets, classifying it as a communicable disease. This type of infectious disorder highlights the need for effective prevention and control measures in communities to limit transmission.
A: Localized. This classification refers to infections confined to a specific area, which does not apply to influenza, as it is widespread and can affect multiple individuals simultaneously.
B: Generalized. This term describes systemic infections affecting the entire body, yet influenza primarily manifests through respiratory symptoms and localized effects, making this label unsuitable.
D: Health-care-associated. This category pertains to infections acquired in healthcare settings; influenza typically spreads in the community rather than being specifically linked to medical environments or procedures.
Correct Answer: C
Rationale: Communicable disease. Influenza spreads easily between individuals through respiratory droplets, classifying it as a communicable disease. This type of infectious disorder highlights the need for effective prevention and control measures in communities to limit transmission.
A: Localized. This classification refers to infections confined to a specific area, which does not apply to influenza, as it is widespread and can affect multiple individuals simultaneously.
B: Generalized. This term describes systemic infections affecting the entire body, yet influenza primarily manifests through respiratory symptoms and localized effects, making this label unsuitable.
D: Health-care-associated. This category pertains to infections acquired in healthcare settings; influenza typically spreads in the community rather than being specifically linked to medical environments or procedures.
Question 24
Regular
The nurse is caring for a client who has acquired immunodeficiency disease (AIDS) and has developed oral thrush. What type of infection is the nurse aware that has developed due to the immunocompromised state of the client?
Correct!
Incorrect
The correct answer is: D
Rationale
Oral thrush in this client represents an opportunistic infection, which occurs when the immune system is weakened, allowing normally harmless organisms to cause disease. This aligns with the nature of AIDS-related complications.
A: Acute An acute infection typically arises suddenly and is often short-lived, differing from the process that leads to opportunistic infections in immunocompromised patients.
B: Chronic A chronic infection persists over a long period, which does not accurately describe the immediate risk posed by opportunistic infections in clients with AIDS.
C: Secondary Secondary infections result from an initial primary infection, whereas oral thrush specifically arises due to the vulnerability of the immune system, making it an opportunistic infection.
Correct Answer: D
Rationale: Oral thrush in this client represents an opportunistic infection, which occurs when the immune system is weakened, allowing normally harmless organisms to cause disease. This aligns with the nature of AIDS-related complications.
A: Acute An acute infection typically arises suddenly and is often short-lived, differing from the process that leads to opportunistic infections in immunocompromised patients.
B: Chronic A chronic infection persists over a long period, which does not accurately describe the immediate risk posed by opportunistic infections in clients with AIDS.
C: Secondary Secondary infections result from an initial primary infection, whereas oral thrush specifically arises due to the vulnerability of the immune system, making it an opportunistic infection.
Question 25
Regular
A client informs the nurse, 'I think I am getting sick.' The chief symptoms of the client are low-grade fever, headache, and having no energy. What stage of the infection does the nurse recognize the client is experiencing?
Correct!
Incorrect
The correct answer is: B
Rationale
The client is experiencing the prodromal stage. This phase is characterized by early, nonspecific symptoms such as low-grade fever, headache, and malaise, indicating the onset of an infection before more severe symptoms develop.
A: Incubation period This phase involves the time between pathogen entry and symptom onset, where the client would not yet exhibit symptoms, making it inconsistent with the reported feelings of illness.
C: Acute stage During the acute stage, symptoms are typically more severe and pronounced, which contrasts sharply with the client's low-grade fever and mild symptoms, indicating they are not in this phase.
D: Convalescent stage This stage occurs after the peak of an infection when symptoms begin to resolve. The client's report of feeling unwell clearly indicates they are not recovering yet.
Correct Answer: B
Rationale: The client is experiencing the prodromal stage. This phase is characterized by early, nonspecific symptoms such as low-grade fever, headache, and malaise, indicating the onset of an infection before more severe symptoms develop.
A: Incubation period This phase involves the time between pathogen entry and symptom onset, where the client would not yet exhibit symptoms, making it inconsistent with the reported feelings of illness.
C: Acute stage During the acute stage, symptoms are typically more severe and pronounced, which contrasts sharply with the client's low-grade fever and mild symptoms, indicating they are not in this phase.
D: Convalescent stage This stage occurs after the peak of an infection when symptoms begin to resolve. The client's report of feeling unwell clearly indicates they are not recovering yet.
Question 26
Regular
The nurse is caring for a group of five clients at the hospital. To control infections when caring for the group of clients, what intervention can the nurse perform?
Correct!
Incorrect
The correct answer is: A
Rationale
A: Use standard precautions with all clients.
Employing standard precautions universally ensures that the nurse minimizes the risk of infection transmission, promoting safety for both clients and healthcare personnel, regardless of the client’s infection status.
B: Only use standard precautions with clients who have an infection.
Limiting precautions to infected clients neglects the potential for asymptomatic transmission, which can compromise overall safety and elevate infection risks for other clients and staff.
C: Wear a mask while taking care of all clients and changing the mask between clients.
Using only masks does not address all aspects of infection control; comprehensive standard precautions encompass hand hygiene, proper glove use, and environmental cleaning beyond just masking.
D: Place the clients on isolation precautions.
Implementing isolation for all clients is impractical and unnecessary. It can lead to social isolation, increased workload, and resource utilization without addressing the broader need for standard infection control practices.
Correct Answer: A
Rationale: A: Use standard precautions with all clients.
Employing standard precautions universally ensures that the nurse minimizes the risk of infection transmission, promoting safety for both clients and healthcare personnel, regardless of the client’s infection status.
B: Only use standard precautions with clients who have an infection.
Limiting precautions to infected clients neglects the potential for asymptomatic transmission, which can compromise overall safety and elevate infection risks for other clients and staff.
C: Wear a mask while taking care of all clients and changing the mask between clients.
Using only masks does not address all aspects of infection control; comprehensive standard precautions encompass hand hygiene, proper glove use, and environmental cleaning beyond just masking.
D: Place the clients on isolation precautions.
Implementing isolation for all clients is impractical and unnecessary. It can lead to social isolation, increased workload, and resource utilization without addressing the broader need for standard infection control practices.
Question 27
Regular
The nurse gave a client an injection and, when attempting to recap the needle, sustained a needlestick injury to the finger. What is the priority action by the nurse?
Correct!
Incorrect
The correct answer is: A
Rationale
Report the injury or exposure to the supervisor. Immediate reporting is crucial for proper documentation, assessment of exposure risk, and initiation of necessary protocols, ensuring the nurse receives appropriate support and intervention.
B: Document the injury in writing. While documentation is important, it is secondary to immediately reporting the injury to ensure timely response and risk management.
C: Receive instructions on monitoring potential symptoms and medical follow-up. Monitoring for symptoms is vital, yet it cannot take precedence over the immediate obligation to report the injury to the supervisor.
D: Receive the most appropriate postexposure prophylaxis. Postexposure prophylaxis is essential but should follow the initial step of reporting the injury to ensure all appropriate measures are implemented.
Correct Answer: A
Rationale: Report the injury or exposure to the supervisor. Immediate reporting is crucial for proper documentation, assessment of exposure risk, and initiation of necessary protocols, ensuring the nurse receives appropriate support and intervention.
B: Document the injury in writing. While documentation is important, it is secondary to immediately reporting the injury to ensure timely response and risk management.
C: Receive instructions on monitoring potential symptoms and medical follow-up. Monitoring for symptoms is vital, yet it cannot take precedence over the immediate obligation to report the injury to the supervisor.
D: Receive the most appropriate postexposure prophylaxis. Postexposure prophylaxis is essential but should follow the initial step of reporting the injury to ensure all appropriate measures are implemented.
Question 28
Regular
The nurse is caring for a client with an abscess on the back. The nurse observes purulent drainage coming from the abscess. What type of specimen does the nurse anticipate the physician will order to determine the type of bacteria present in the exudate?
Correct!
Incorrect
The correct answer is: D
Rationale
A culture. This test is essential for identifying the specific bacteria causing the infection by growing the microorganisms from the purulent drainage, allowing for targeted treatment based on the results.
A: A sensitivity test evaluates how bacteria respond to antibiotics but does not identify the bacteria's presence in the exudate.
B: Test for ova and parasites focuses on detecting parasitic infections, not bacterial pathogens found in an abscess.
C: White blood cell (WBC) count indicates infection presence but does not specify the type of bacteria responsible for the abscess.
Correct Answer: D
Rationale: A culture. This test is essential for identifying the specific bacteria causing the infection by growing the microorganisms from the purulent drainage, allowing for targeted treatment based on the results.
A: A sensitivity test evaluates how bacteria respond to antibiotics but does not identify the bacteria's presence in the exudate.
B: Test for ova and parasites focuses on detecting parasitic infections, not bacterial pathogens found in an abscess.
C: White blood cell (WBC) count indicates infection presence but does not specify the type of bacteria responsible for the abscess.
Question 29
Regular
A nurse is having a yearly employee tuberculin skin test. Which skin test results would indicate a positive result?
Correct!
Incorrect
The correct answer is: A
Rationale
An induration of 12 mm indicates a positive result for the tuberculin skin test. This measurement surpasses the threshold that signals potential tuberculosis infection, suggesting significant immune response and warranting further evaluation.
B: An uneven erythemic area does not quantify the induration necessary for a positive result, as erythema alone does not indicate infection or immune response.
C: An induration of less than 1 mm fails to meet the minimum criteria for a positive test result, indicating no significant immune reaction to the tuberculin.
D: An induration of 4 mm is insufficient to classify as positive, as it does not reach the level that reflects a notable immune response to the tuberculin antigen.
Correct Answer: A
Rationale: An induration of 12 mm indicates a positive result for the tuberculin skin test. This measurement surpasses the threshold that signals potential tuberculosis infection, suggesting significant immune response and warranting further evaluation.
B: An uneven erythemic area does not quantify the induration necessary for a positive result, as erythema alone does not indicate infection or immune response.
C: An induration of less than 1 mm fails to meet the minimum criteria for a positive test result, indicating no significant immune reaction to the tuberculin.
D: An induration of 4 mm is insufficient to classify as positive, as it does not reach the level that reflects a notable immune response to the tuberculin antigen.
Question 30
Regular
A client is hospitalized for an infected decubitus ulcer of the sacral area. The physician is planning to remove the dead and damaged tissue. What type of procedure will the nurse prepare the client for?
Correct!
Incorrect
The correct answer is: B
Rationale
Debridement involves the surgical removal of dead or damaged tissue, which is essential in treating infected decubitus ulcers. This procedure promotes healing by eliminating necrotic material and reducing the risk of further infection.
A: Application of a dry dressing provides protection to the wound but does not address the underlying issue of dead tissue, which is crucial for healing.
C: Administration of filgrastim (Neupogen) stimulates white blood cell production, assisting in infection management but does not directly remove necrotic tissue from the ulcer.
D: Injecting antibiotics into the wound may help combat infection but does not facilitate the necessary removal of dead tissue, which is vital for effective treatment.
Correct Answer: B
Rationale: Debridement involves the surgical removal of dead or damaged tissue, which is essential in treating infected decubitus ulcers. This procedure promotes healing by eliminating necrotic material and reducing the risk of further infection.
A: Application of a dry dressing provides protection to the wound but does not address the underlying issue of dead tissue, which is crucial for healing.
C: Administration of filgrastim (Neupogen) stimulates white blood cell production, assisting in infection management but does not directly remove necrotic tissue from the ulcer.
D: Injecting antibiotics into the wound may help combat infection but does not facilitate the necessary removal of dead tissue, which is vital for effective treatment.
Question 31
Regular
A client is in the acute care facility for the administration of intravenous (IV) antibiotics to treat bacterial pneumonia. The client begins to have severe diarrhea 3 days after the IV antibiotics with abdominal cramping and pain. What does the nurse suspect the client has developed due to the antibiotic use?
Correct!
Incorrect
The correct answer is: D
Rationale
D: Pseudomembranous colitis is suspected as it commonly occurs after antibiotic use, leading to symptoms such as severe diarrhea and abdominal cramping due to Clostridium difficile overgrowth in the intestines.
A: Food poisoning typically arises from contaminated food and presents more abruptly, often with nausea and vomiting, rather than being linked specifically to antibiotic treatment.
B: An allergic reaction to the antibiotic usually manifests with symptoms like rash or anaphylaxis, rather than gastrointestinal distress such as severe diarrhea and cramping.
C: A helminth infection is characterized by different symptoms, such as weight loss or gastrointestinal obstruction, and is not directly associated with antibiotic use and subsequent diarrhea.
Correct Answer: D
Rationale: D: Pseudomembranous colitis is suspected as it commonly occurs after antibiotic use, leading to symptoms such as severe diarrhea and abdominal cramping due to Clostridium difficile overgrowth in the intestines.
A: Food poisoning typically arises from contaminated food and presents more abruptly, often with nausea and vomiting, rather than being linked specifically to antibiotic treatment.
B: An allergic reaction to the antibiotic usually manifests with symptoms like rash or anaphylaxis, rather than gastrointestinal distress such as severe diarrhea and cramping.
C: A helminth infection is characterized by different symptoms, such as weight loss or gastrointestinal obstruction, and is not directly associated with antibiotic use and subsequent diarrhea.
Question 32
Regular
The nurse has been injured with a needlestick while caring for a newly admitted client and informs the charge nurse. What is the next thing the injured nurse should do?
Correct!
Incorrect
The correct answer is: A
Rationale
Documentation of the injury in writing is the next step for the injured nurse. This ensures a clear record of the incident, which is essential for follow-up actions, reporting, and compliance with health protocols.
B: Obtain the client's HIV status. While important, this step does not address immediate procedural requirements following the injury and can occur after documentation.
C: Get instructions on monitoring potential symptoms. Monitoring potential symptoms is crucial, yet it follows the priority of documenting the injury and ensuring proper reporting protocols are in place first.
D: Report the injury to the supervisor. Reporting is vital, but proper documentation takes precedence to create an accurate record before any further actions or investigations are initiated.
Correct Answer: A
Rationale: Documentation of the injury in writing is the next step for the injured nurse. This ensures a clear record of the incident, which is essential for follow-up actions, reporting, and compliance with health protocols.
B: Obtain the client's HIV status. While important, this step does not address immediate procedural requirements following the injury and can occur after documentation.
C: Get instructions on monitoring potential symptoms. Monitoring potential symptoms is crucial, yet it follows the priority of documenting the injury and ensuring proper reporting protocols are in place first.
D: Report the injury to the supervisor. Reporting is vital, but proper documentation takes precedence to create an accurate record before any further actions or investigations are initiated.
Question 33
Multiple Choice
The nurse is caring for a client with breast cancer who has been receiving chemotherapy. The client was admitted with an infected lesion on their left leg. The health care provider has ordered filgrastim. What will filgrastim do for this client? Select all that apply.
Correct!
Incorrect
The correct answer is: B,C
Rationale
Filgrastim will boost the immune system and increase white blood cell production for this client.
Filgrastim stimulates the bone marrow to produce more neutrophils, enhancing the body’s ability to fight infections, which is crucial given the client's chemotherapy treatment and infected lesion.
A: Increase platelet count. Filgrastim specifically targets white blood cells, not platelets, so it does not contribute to increasing platelet levels in the blood.
D: Boost red blood cell production. This medication focuses on white blood cells, and does not influence red blood cell production, which is managed by other factors.
E: Increase hematocrit level. Hematocrit levels relate to red blood cell volume, not white blood cell counts, making this outcome unrelated to the action of filgrastim.
Correct Answer: B,C
Rationale: Filgrastim will boost the immune system and increase white blood cell production for this client.
Filgrastim stimulates the bone marrow to produce more neutrophils, enhancing the body’s ability to fight infections, which is crucial given the client's chemotherapy treatment and infected lesion.
A: Increase platelet count. Filgrastim specifically targets white blood cells, not platelets, so it does not contribute to increasing platelet levels in the blood.
D: Boost red blood cell production. This medication focuses on white blood cells, and does not influence red blood cell production, which is managed by other factors.
E: Increase hematocrit level. Hematocrit levels relate to red blood cell volume, not white blood cell counts, making this outcome unrelated to the action of filgrastim.
Question 34
Multiple Choice
A client is suspected of sepsis from a postsurgical incision infection. What characteristic(s) of sepsis would the nurse recognize? Select all that apply.
Correct!
Incorrect
The correct answer is: A,B,C
Rationale
A: Temperature of 102 F, Heart rate of 120 beats/minute, Respiratory rate of 24 breaths/minute. These signs indicate a hypermetabolic state often associated with sepsis, reflecting the body's response to infection and systemic inflammation.
D: PaCO2 of 42 mm Hg indicates normal respiratory function. In sepsis, abnormalities in gas exchange or respiratory distress are more common, making this value less relevant to the diagnosis.
E: Blood pressure of 120/80 mm Hg represents a normal reading. While hypotension may be a concern in sepsis, this value does not indicate any significant deviation from normal physiological parameters.
Correct Answer: A,B,C
Rationale: A: Temperature of 102 F, Heart rate of 120 beats/minute, Respiratory rate of 24 breaths/minute. These signs indicate a hypermetabolic state often associated with sepsis, reflecting the body's response to infection and systemic inflammation.
D: PaCO2 of 42 mm Hg indicates normal respiratory function. In sepsis, abnormalities in gas exchange or respiratory distress are more common, making this value less relevant to the diagnosis.
E: Blood pressure of 120/80 mm Hg represents a normal reading. While hypotension may be a concern in sepsis, this value does not indicate any significant deviation from normal physiological parameters.