ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 12 : Infection Questions
Question 1 of 5
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 Answer: C
Rationale: Catheters provide a portal for infection because they are invasive. Although catheters are not used as frequently in older adults for the control of urinary incontinence, there are some bed-confined clients who use them. Family requests for catheters may be considered, but physicians make the decision if it will benefit the client. Catheters are not flushed daily with anything.
Question 2 of 5
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 Answer: A
Rationale: The acid environment is unfavorable for the multiplication of pathogenic bacteria and fungi. A change in vaginal pH or destruction of the normal flora, however, can promote the development of a vaginal infection. Bacteria do not cause the vaginal pH to change; the pH change allows bacteria to grow. Change in vaginal pH does not cause an allergic reaction and does not allow the development of cancer cells.
Question 3 of 5
A client is admitted to an acute care facility with a diagnosis of appendicitis. Which laboratory results demonstrate the client's leukocytosis?
Correct Answer: D
Rationale: The body manufactures more WBCs as needed, a process referred to as leukocytosis. The WBC of 22,000 cells/mms indicates an abundance of white blood cells. Hemoglobin does not represent the presence of infection. The lymphocytes and neutrophils are within normal range and do not demonstrate leukocytosis.
Question 4 of 5
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 Answer: B
Rationale:
To prevent the spread of pathogens to adjacent tissues, a fibrin barrier forms around the injured area. Inside the barrier, a thick, white exudate (pus) accumulates. This collection of pus is called an abscess, which may break through the skin and drain or continue to enlarge internally. A lesion would not be filled with pus, nor would a cancerous tumor. A fluid-filled vesicle is associated with a viral type illness.
Question 5 of 5
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 Answer: C
Rationale: Healthcare-associated infections are infections acquired while receiving care in a healthcare agency that were not active, incubatory, or chronic at admission. They occur for many reasons. Hospitalized clients are more susceptible to infections than well people because they are exposed to pathogens in the healthcare environment; may have incisions or invasive equipment (e.g., IV lines) that compromise skin integrity; or may be immunosuppressed from poor nutrition, their disease process, or its treatment. Also, because healthcare personnel are in frequent and direct contact with many clients who harbor various microorganisms, the risk for transmitting pathogenic microorganisms between and among clients is high. Allergic reaction to the IV, the nurse developing the same symptoms, and dislodging of the IV catheter are not the priority concerns.