The nursing instructor explaining infection tells students that which factor is the best and most important barrier to infection?
Skin and mucous membranes
A nursing manager is concerned about the number of infections on the hospital unit. What action by the manager would best help prevent these infections?
Auditing staff members hand hygiene practices
A student nurse asks why brushing clients teeth with a toothbrush in the intensive care unit is important to infection control. What response by the registered nurse is best?
It mechanically removes biofilm on teeth.
A client is admitted with possible sepsis. Which action should the nurse perform first?
Obtain specified cultures.
A client is hospitalized and on multiple antibiotics. The client develops frequent diarrhea. What action by the nurse is most important?
Consult with the provider about obtaining stool cultures.
A nurse is observing as an unlicensed assistive personnel (UAP) performs hygiene and changes a clients bed linens. What action by the UAP requires intervention by the nurse?
Shaking dirty linens and placing them on the floor
A hospital unit is participating in a bioterrorism drill. A client is admitted with inhalation anthrax. Under what type of precautions does the charge nurse admit the client?
Standard Precautions
Which action by the nurse is most helpful to prevent clients from acquiring infections while hospitalized?
Consistently using appropriate hand hygiene
A client is admitted with fever, myalgia, and a papular rash on the face, palms, and soles of the feet. What action should the nurse take first?
Place the client on Airborne Precautions.
A client has been placed on Contact Precautions. The clients family is very afraid to visit for fear of being contaminated by the client. What action by the nurse is best?
Inform them that the infection is the issue, not the client.
A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) infection cultured from the urine. What action by the nurse is most appropriate?
Prepare to administer vancomycin (Vancocin).
A hospitalized client is placed on Contact Precautions. The client needs to have a computed tomography (CT) scan. What action by the nurse is most appropriate?
Ensure that the radiology department is aware of the isolation precautions.
A client has a wound infection to the right arm. What comfort measure can the nurse delegate to the unlicensed assistive personnel (UAP)?
Elevate the arm above the level of the heart
A nurse receives report from the laboratory on a client who was admitted for fever. The laboratory technician states that the client has a shift to the left on the white blood cell count. What action by the nurse is most important?
Notify the provider and request antibiotics.
A client has been admitted to the hospital for a virulent infection and is started on antibiotics. The client has laboratory work pending to determine if the diagnosis is meningitis. After starting the antibiotics, what action by the nurse is best?
Assess the client frequently for worsening of his or her condition.
The student nurse caring for clients understands that which factors must be present to transmit infection? (Select all that apply.)
Host
Mode of transmission
Portal of entry
Reservoir
Which statements are true regarding Standard Precautions? (Select all that apply.)
Use personal protective equipment as needed for client care.
Wear gloves when touching client excretions or secretions.
The student nurse learns that effective antimicrobial therapy requires which factors to be present? (Select all that apply.)
Appropriate drug
Proper route of administration
Sufficient dose
Sufficient length of treatment
A client is being admitted with suspected tuberculosis (TB). What actions by the nurse are best? (Select all that apply.)
Admit the client to a negative-airflow room.
Order specialized masks/respirators for caregiving
A student nurse asks the nursing instructor why older adults are more prone to infection than other adults. What reasons does the nursing instructor give? (Select all that apply.)
Age-related decrease in immune function
Decreased cough and gag reflexes
Diminished acidity of gastric secretions
Thinning skin that is less protective
A client with an infection has a fever. What actions by the nurse help increase the clients comfort? (Select all that apply.)
Change the clients gown and linens when damp.
Offer cool fluids to the client frequently.
While assessing a client, a nurse detects a bluish tinge to the clients palms, soles, and mucous membranes. Which action should the nurse take next?
Use pulse oximetry to assess the clients oxygen saturation
A nurse assesses a client who is admitted with inflamed soft-tissue folds around the nail plates. Which question should the nurse ask to elicit useful information about the possible condition?
What do you do for a living?
A nurse assesses a client who has multiple areas of ecchymosis on both arms. Which question should the nurse ask first?
What medications are you taking?
After teaching a client who expressed concern about a rash located beneath her breast, a nurse assesses the clients understanding. Which statement indicates the client has a good understanding of this condition?
I can use powder to keep this area dry.
A nurse assesses a client who has two skin lesions on his chest. Each lesion is the size of a nickel, flat, and darker in color than the clients skin. How should the nurse document these lesions?
Two 2-cm hyperpigmented patches
While assessing a clients lower extremities, a nurse notices that one leg is pale and cooler to the touch. Which assessment should the nurse perform next?
Palpate the clients pedal pulses bilaterally.
A nurse cares for an older adult client who has a chronic skin disorder. The client states, I have not been to church in several weeks because of the discoloration of my skin. How should the nurse respond?
Tell me more about your concerns related to your skin.
A nurse assesses a client who has open lesions. Which action should the nurse take first?
Put on gloves.
A nurse assesses a client who has a chronic skin disorder. Which finding indicates the client is effectively coping with the disorder
Clean hair and nails
A nurse assesses a client and identifies that the client has pallor conjunctivae. Which focused assessment should the nurse complete next?
Hemoglobin and hematocrit
During skin inspection of a client, a nurse observes lesions with wavy borders that are widespread across the clients chest. Which descriptors should the nurse use to document these observations?
Linear and circinate
A nurse assesses an older adult client with the skin disorder shown below: How should the nurse document this finding?
Petechiae
A nurse assesses an older adults skin. Which findings require immediate referral? (Select all that apply.)
Lesion with various colors
Asymmetric 6-mm dark lesion on forehead
A nurse plans care for a client who has a wound that is not healing. Which focused assessments should the nurse complete to develop the clients plan of care? (Select all that apply.)
Height
Alcohol use
Prealbumin laboratory results
A nurse teaches a client to perform total skin self-examinations on a monthly basis. Which statements should the nurse include in this clients teaching? (Select all that apply.)
Look for asymmetry of shape and irregular borders.
Assess for color variation within each lesion