ATI Care of Patients with Infection, Questions and Answers with Explanations

ATI Care of Patients with Infection, Questions and Answers with Explanations, 100% Correct, Download to Score A

Test Bank

MULTIPLE CHOICE

1. After an infection control in-service, which statement by the nurse demonstrates an accurate understanding of the mode of transmission of influenza?

a.            “I will not develop the infection unless I have physical contact with the client.”

b.            “I should wear an N95 respirator to provide care for the client with influenza.”

c.             “I should try to stay at least 3 feet away from the client, if at all possible.”

d.            “The infection is spread through droplets suspended in the air and inhaled.”

ANS: C

Influenza is transmitted via droplets. Droplets are produced when a person talks or sneezes and travel short distances (up to 3 feet) but are not suspended in the air for long. Staff should stay at least 3 feet (1 m) away from a client with droplet infection. Actual physical contact with the client is not necessary for infection to occur. It is not necessary for staff to wear an N95 respirator mask for Droplet Precautions; these masks are used in the care of clients with tuberculosis.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC: Integrated Process: Nursing Process (Planning)

2. The nurse is told that a client with measles is being admitted. Which action by the nurse is best?

a.            Implement Contact Precautions.

b.            Check negative airflow monitors.

c.             Ensure that hand sanitizer is readily available.

d.            Place the client in a room with another measles client.

ANS: B

Clients with measles require Airborne Precautions, which include being placed in a room with specially monitored negative airflow. Before admitting the client with measles, the nurse should ensure that the airflow monitors are working properly. Contact Precautions are not used for measles. Having hand sanitizer is always a good idea, but it is not the most important action. Placing the client with another measles client is a possible action if more than one case is present (e.g., during an outbreak), but the most important thing is to ensure that Airborne Precautions can be maintained for safety.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC: Integrated Process: Nursing Process (Planning)

3. A client and his family are waiting for the results of clinical tests to determine whether the client has an infection. They are becoming anxious. What is the most important assessment that the nurse should make of the client and family members?

a.            Understanding of insurance reimbursement for testing

b.            Use of appropriate coping mechanisms for anxiety

c.             Understanding of the infectious disease process

d.            Understanding of the diagnostic procedures

ANS: D

Assess the client’s and family’s level of understanding about various diagnostic procedures and the time required to obtain test results. This is more important than whether the family has any understanding of their insurance and will help reduce anxiety if understanding is accurate. The client with an infectious disease often has psychosocial concerns. Delay in diagnosis caused by the need to wait for clinical test results produces anxiety. Plan education on infection risk reduction when the client and the family are ready to learn.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)

MSC: Integrated Process: Nursing Process (Assessment)

4. The nurse is preparing to administer a prescribed IV antibiotic to a client admitted with a serious infection. Which action by the nurse is most important?

a.            Check the IV for patency.

b.            Assess the client for allergies.

c.             Double check the “five rights.”

d.            Teach the client about the drug.

ANS: B

All actions are appropriate and important before administering any medications. However, client safety is the priority. The nurse should first assess the client for medication allergies by asking the client or checking the chart (or both). Ensuring a patent IV and checking the five rights will not protect the client from an allergic reaction.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Accident/Injury Prevention)

MSC: Integrated Process: Nursing Process (Implementation)

5. A client is being treated with acetaminophen (Tylenol). Which assessment finding is most likely to occur after a dose of the medication?

a.            A febrile seizure

b.            Nausea and vomiting

c.             Episodes of sweating

d.            Syncope

ANS: C

Be alert for waves of sweating after each dose. Sweating may be accompanied by a fall in blood pressure, followed by return of fever. These unpleasant side effects of antipyretic therapy often can be alleviated by liberal administration of fluids and by regular scheduling of drug administration.

DIF: Cognitive Level: Knowledge/Remembering REF: p. 446

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Side Effects/Interactions)

MSC: Integrated Process: Nursing Process (Assessment)

6. Which client does the nurse consider to be at increased risk for infection?

a.            Young adult who wears contact lenses

b.            Adult with type 1 diabetes mellitus

c.             Adult with known hypersensitivity to latex

d.            Adolescent using analgesics for migraine headaches

ANS: B

Clients with diabetes are at greater risk for infection for many reasons. The disease affects the vascular system, preventing normal immune defenses from reaching sites of injury or invasion. The elevated glucose level in the extracellular fluid provides a rich growth medium for microorganisms, especially bacteria and fungi. Wearing contact lenses might put a client at slightly higher risk for eye infection. Hypersensitivity to latex puts a client at risk for anaphylaxis, but not at increased risk for infection. The use of analgesics will not put a client at risk for infection.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 444

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Assessment)

7. The nurse is assigned to work with a new nursing assistant. Which action by the nursing assistant requires intervention by the registered nurse?

a.            Using an alcohol-based hand rub after caring for a client with diarrhea

b.            Washing hands for 20 seconds using warm water and friction

c.             Cleaning especially carefully under fingernails and around a wedding band

d.            Using chlorhexidine for handwashing when caring for clients on neutropenic precautions

ANS: A

Alcohol-based hand rubs are not effective against spore-forming organisms such as Clostridium difficile, which is a common cause of diarrhea among hospitalized clients. The nursing assistant should wash hands with soap after caring for such clients in case they have an undiagnosed infection with this bacterium. The other actions are appropriate.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC: Integrated Process: Communication and Documentation

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Category ATI
Release date 2021-09-14
Pages 11
Language English
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