Ch 31 practice questions – Flashcards
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The nurse works on a long-term care unit. In the last 2 weeks more than half the clients on the unit have been diagnosed with gastroenteritis. What is the most likely reason?
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The infection is being transmitted by health care personnel.
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A nurse is palpating the cervical lymph nodes of a client with a suspected upper respiratory infection. Which finding would help to support the suspicion of an infection?
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tenderness
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A nurse is reviewing a client's complete white blood cell (WBC) count and differential. The nurse determines that the client is experiencing neutropenia based on which absolute neutrophil count?
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800 cells/mm3
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Infection occurs when the host is exposed to pathogens. What type of pathogen uses the cell's metabolism, and replicates itself while destroying the cell or changing the cell's genetic makeup?
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Virus
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The postoperative client refuses to do deep breathing, and he refuses to turn while in bed. He informs the nurse that it hurts for him to do both of these things. Which intervention should the nurse perform first?
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Assess client's pain level and manage pain accordingly.
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The nurse has admitted a new client to the unit. This client has an open draining sore on the leg. Which diagnostic test would the nurse anticipate being ordered?
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culture and sensitivity
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Microorganisms that are present on the human body without host interference or interaction refers to:
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colonization
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A client has had abdominal surgery. During a follow-up visit to the surgeon on the tenth postoperative day, the client exhibits a fever. The nurse suspects which of the following as the most likely cause?
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Wound infection
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A client who comes to the clinic asks the nurse, "Somebody told me that stress increases my risk for infection. How does this happen?" Which response by the nurse would be most appropriate?
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"Stress leads to increased secretion of cortisol, which suppreses your immune response."
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The nurse is reviewing the urine analysis results for the client who is confused and agitated. Which lab result clearly indicates urinary tract infection.
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pH of 8.5
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A nurse in an oncology care unit is reviewing the laboratory test results of several clients. The nurse identifies that the client with which leukocyte count most likely has an infection?
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18,000 cells/mm
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A nurse in an oncology care unit is reviewing the laboratory test results of several clients scheduled to receive chemotherapy. The nurse determines that the client with which leukocyte count will most likely have the chemotherapy withheld?
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2,500 cells/mm3
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After educating students about changes in the immune system and risk for infection as people age, the instructor determines that the education was successful when the students identify:
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decreased cellular immunity.
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A nurse is working with an 82-year-old man following gallbladder surgery. He is n.p.o. and has IV access in his hand. He also has a Foley catheter in place. He is able to ambulate with the aid of a walker. What does not lower this client's immunity?
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Ambulation
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A nurse is working with a young woman, age 15, in a community health clinic. It is early October, and the young woman is worried that she will become ill and miss school, stating "I am always getting sick this time of year." What health promotion activities are appropriate to include in the nurse's teaching today? Select all that apply.
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proper handwashing techniques information on sleep hygiene administration of influenza immunization
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A client the nurse is caring for has developed a bladder infection while in the hospital. The client has had a Foley catheter for 2 weeks. The client's family asks the nurse how the client got this infection. What would be the nurse's best response?
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"People in hospitals are often more susceptible to infections because they are already ill and they are exposed to germs while they are in the hospital."
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The nurse is assessing a client with an elevated temperature. Which of the following would lead the nurse to determine that the client is in the fever phase?
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Skin warm and flushed
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Every 2 hours, the nurse turns and repositions the client who is experiencing frequent diarrhea. This action supports, among other things, infection prevention. Which assessment indicates that there is a positive outcome from this nursing care?
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skin is dry and intact
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The nurse is educating the client on culture and sensitivity test. The client wants know to when the nurse could get the results back. Which response should the nurse use?
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"It could take 24 to 36 hours to grow cultures and about 48 hours for sensitivity."
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The nurse is speaking to the physician regarding the client's frequent diarrhea episode since starting IV antibiotics. The nurse states "I am concerned that Mr. Clark has developed Clostridium Difficile infection". Which part of the SBAR communication will this statement fall into?
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A= Assessment
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A nurse is caring for a client who has neutropenia resulting from chemotherapy. Which precaution would be least appropriate to include when caring for this client?
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obtaining rectal temperatures
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A nurse is reviewing the laboratory test results of a client who is at high risk for septic shock. Which serum lactate level would the nurse identify as indicating sepsis?
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3.2 mmol/L
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The nurse is caring for a client with an impaired immune system. The nurse is concerned about the client acquiring a healthcare-associated infection (HAI). What intervention would the nurse focus on to help control HAIs?
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Apply principles of medical and surgical asepsis.
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A client has a concentration of Staphylococcus aureus located on his skin. He is not showing signs of increased temperature, redness, or pain at the site. The nurse is aware that this is a sign of a microorganism at which stage?
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Colonization
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Infection occurs when the host is exposed to pathogens. What type of pathogen uses the cell's metabolism, and replicates itself while destroying the cell or changing the cell's genetic makeup?
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Virus
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The mother of a newborn asks the nurse about her newborn's risk for infection. Which statement by the nurse would be most appropriate?
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"Your baby's resistance comes from the antibodies you passed on to him before birth and now with breast feeding."
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A client is being screened for a parasitic infection and the physician orders stool specimens. When explaining to the client about collecting the specimens, the nurse would inform the client that the specimens will be collected daily for:
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3 days.
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A nurse is reviewing a client's complete white blood cell (WBC) count and differential. The nurse determines that the client is experiencing neutropenia based on which absolute neutrophil count?
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800 cells/mm3
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A 20-year-old man is seen in a clinic for purulent penile discharge. He discloses that he has had five sexual partners in the past month. The client states that he always uses a condom. Which is the most appropriate NANDA-I nursing diagnosis for the client?
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Risk for Infection related to increased exposure to pathogens
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The nurse is getting ready to change the client's wound dressing. Which step best supports infection control?
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handwashing
