ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 12 : Infection Questions
Question 1 of 5
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 Answer: B
Rationale: Debridement is the removal of dead and damaged tissue surgically. Application of a dry dressing will not debride the wound, nor will the administration of Neupogen or injecting antibiotics into the wound.
Question 2 of 5
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 Answer: D
Rationale: When a client is taking an antibiotic, a superinfection can result from overgrowth of microorganisms not affected by the drug. This can lead to a serious inflammation of the colon called pseudomembranous colitis accompanied by potentially life-threatening diarrhea. The nurse should report fever, abdominal cramps, and severe diarrhea immediately. The other choices are not related to the use of the antibiotics.
Question 3 of 5
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 Answer: A
Rationale: Should an injury occur, health care workers are advised to follow postexposure recommendations: (1) Report the injury to one's supervisor immediately; (2) document the injury in writing; (3) identify the person or source of blood, if possible; and (4) obtain the HIV and hepatitis B statuses of the source of blood, if it is legal to do so. Unless the client gives permission, testing and revealing HIV status are prohibited; (5) obtain counseling on the potential for infection; (6) receive the most appropriate postexposure prophylaxis; (7) be tested for disease antibodies at appropriate intervals; and (8) receive instructions on monitoring potential symptoms and medical follow-up.
Question 4 of 5
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 Answer: B,C
Rationale: Bone marrow transplantation or administration of drugs that boost white blood cell production, such as filgrastim, may help immunosuppressed clients. Neupogen does not increase the platelet count, hematocrit level, or boost red blood cell production.
Question 5 of 5
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 Answer: A,B,C
Rationale: Two or more of the following characterize sepsis: temperature greater than 100.4 F (38
C), heart rate greater than 90 beats/minute, respiratory rate greater than 20 breaths/minute or PaCO2 less than 32 mm Hg, WBC count greater than 12,000 cells/mm, or 10% immature (band) forms. Blood pressure is not an indicator of sepsis, and a PaCO2 of 42 mm Hg is not an indicator.