ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 12 : Infection Questions
Question 1 of 5
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 Answer: C
Rationale: A heart rate greater than 90 beats/minute or a respiratory rate greater than 20 breaths/minute will indicate that sepsis has occurred. Sepsis does not increase the client's appetite or affect the client's urinary output.
Question 2 of 5
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 Answer: C
Rationale:
To help prevent and control community-acquired infections, nurses should encourage childhood immunizations. Vaccines stimulate the body to produce antibodies against a specific disease organism. The immunization protects children as well as adults who may not have developed sufficient immunity. Following a proper diet and exercise regimen and going for regular check-ups are important, but these measures do not help prevent or control community-acquired infections. Smoking cessation does not reduce the risk of such infections either.
Question 3 of 5
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 Answer: C
Rationale: Hand hygiene remains the single most important measure to prevent the spread of infection. It reduces the number of transient and resident microorganisms. Sufficient food intake helps restore biologic defense mechanisms but does not prevent spread of infections. Although minimal social contact and regular immunizations may help prevent the spread of infection, especially community-acquired infections, these are not practical measures.
Question 4 of 5
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 Answer: C
Rationale: If a needlestick injury has occurred, the nurse should be tested for disease antibodies immediately and at appropriate intervals thereafter. The nurse should document the injury in writing immediately and should not wait until the client's infectious status is confirmed. The nurse should also notify the supervisor of the injury immediately and identify the person or source of blood, if possible.
Question 5 of 5
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 Answer: A
Rationale: A client with fever and diarrhea should avoid tea, coffee, and carbonated beverages containing caffeine because these promote diuresis. The intake of ice water, broth, fruit juices, gelatin, and milk should be encouraged to add proteins and calories.