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 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 2 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.
Question 3 of 5
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 Answer: B
Rationale: A culture identifies bacteria in a specimen taken from a person with symptoms of an infection. The source of the specimen may be body fluids or wastes, such as blood, sputum, urine, or feces, or the purulent exudate, collection of pus, from an open wound. A platelet count would not tell the nurse about the infection. A sputum culture would not be indicated for a leg wound, nor would a urinalysis.
Question 4 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 5 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.