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
Category | ATI |
Release date | 2021-09-14 |
Pages | 11 |
Language | English |
Comments | 0 |
Sales | 0 |
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