8/20/2019 Ramont2e Rev TIF Ch10 http://slidepdf.com/reader/full/ramont2e-rev-tif-ch10 1/40 Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank Chapter 10 Question 1 Type: MCSA The nurse is teaching peers about infection. Which of the following statements made by the nurse is accurate? 1. "Microorganisms are always harmful to the human organism." 2. "An infection is defined as an invasion of the body by any microorganism." . "nfections can be caused by a virus! bacteria! or fungi." !. "Antibiotics are effective for all infections." Corre"t #ns$er: Rationa%e 1# nfections can be caused by a virus! bacteria! or fungi. Microorganisms are not always harmful! and some organisms are important to normal functioning of the body. An infection is defined as an invasion of the body by a disease$causing organism! not %ust any organism. Antibiotics are effective for bacteria! but are not effective against viruses or fungi. Rationa%e 2# nfections can be caused by a virus! bacteria! or fungi. Microorganisms are not always harmful! and some organisms are important to normal functioning of the body. An infection is defined as an invasion of the body by a disease$causing organism! not %ust any organism. Antibiotics are effective for bacteria! but are not effective against viruses or fungi. Rationa%e # nfections can be caused by a virus! bacteria! or fungi. Microorganisms are not always harmful! and some organisms are important to normal functioning of the body. An infection is defined as an invasion of the body by a disease$causing organism! not %ust any organism. Antibiotics are effective for bacteria! but are not effective against viruses or fungi. Rationa%e !# nfections can be caused by a virus! bacteria! or fungi. Microorganisms are not always harmful! and some organisms are important to normal functioning of the body. An infection is defined as an invasion of the body by a disease$causing organism! not %ust any organism. Antibiotics are effective for bacteria! but are not effective against viruses or fungi. &%o'a% Rationa%e: Cogniti(e )e(e%: Applying C%ient Need: &hysiological ntegrity C%ient Need *u': Nursing+ntegrated Con"epts: 'ursing &rocess# Assessment )earning -ut"ome: (efine terms and name helpful and harmful actions of microorganisms. )amont! 'iedringhous! Comprehensive Nursing Care *nd +dition ,pdate Test -an Copyright */0* by &earson +ducation! nc.
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Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test
Bank
Chapter 10Question 1
Type: MCSA
The nurse is teaching peers about infection. Which of the following statements made by the nurse is accurate?
1. "Microorganisms are always harmful to the human organism."
2. "An infection is defined as an invasion of the body by any microorganism."
. "nfections can be caused by a virus! bacteria! or fungi."
!. "Antibiotics are effective for all infections."
Corre"t #ns$er:
Rationa%e 1# nfections can be caused by a virus! bacteria! or fungi. Microorganisms are not always harmful! and
some organisms are important to normal functioning of the body. An infection is defined as an invasion of the
body by a disease$causing organism! not %ust any organism. Antibiotics are effective for bacteria! but are noteffective against viruses or fungi.
Rationa%e 2# nfections can be caused by a virus! bacteria! or fungi. Microorganisms are not always harmful! and
some organisms are important to normal functioning of the body. An infection is defined as an invasion of the
body by a disease$causing organism! not %ust any organism. Antibiotics are effective for bacteria! but are noteffective against viruses or fungi.
Rationa%e # nfections can be caused by a virus! bacteria! or fungi. Microorganisms are not always harmful! and
some organisms are important to normal functioning of the body. An infection is defined as an invasion of the body by a disease$causing organism! not %ust any organism. Antibiotics are effective for bacteria! but are not
effective against viruses or fungi.
Rationa%e !# nfections can be caused by a virus! bacteria! or fungi. Microorganisms are not always harmful! and
some organisms are important to normal functioning of the body. An infection is defined as an invasion of the body by a disease$causing organism! not %ust any organism. Antibiotics are effective for bacteria! but are not
The nurse is woring in an +mergency (epartment! and admits a client believed to be infected by bioterrorism.
Which agencies does the nurse anticipate might be notified? Select all that apply.
*tandard Tet: Select all that apply.
1. World 1ealth 2rgani3ation
2. Centers for (isease Control and &revention
. &ublic 1ealth (epartment
!. (epartment of 1omeland Security
/. The (rug +nforcement Agency
Corre"t #ns$er: *!!4
Rationa%e 1# The Centers for (isease Control and &revention surveys trends! and is the main agency concerned
with protecting the public from disease and controlling spread on a national level. The &ublic 1ealth (epartment
wors at a local level to prevent spread of disease. The (epartment of 1omeland Security would be involved because of concern over potential bioterrorism. The World 1ealth 2rgani3ation would not be involved unless
there were concern about spread of the disease to other parts of the world. The (rug +nforcement Agency contro
use of controlled medication! but would not be involved in an infection outbrea.
Rationa%e 2# The Centers for (isease Control and &revention surveys trends! and is the main agency concernedwith protecting the public from disease and controlling spread on a national level. The &ublic 1ealth (epartment
wors at a local level to prevent spread of disease. The (epartment of 1omeland Security would be involved
because of concern over potential bioterrorism. The World 1ealth 2rgani3ation would not be involved unlessthere were concern about spread of the disease to other parts of the world. The (rug +nforcement Agency contro
use of controlled medication! but would not be involved in an infection outbrea.
Rationa%e # The Centers for (isease Control and &revention surveys trends! and is the main agency concerned
with protecting the public from disease and controlling spread on a national level. The &ublic 1ealth (epartmentwors at a local level to prevent spread of disease. The (epartment of 1omeland Security would be involved
because of concern over potential bioterrorism. The World 1ealth 2rgani3ation would not be involved unless
there were concern about spread of the disease to other parts of the world. The (rug +nforcement Agency controuse of controlled medication! but would not be involved in an infection outbrea.
Rationa%e !# The Centers for (isease Control and &revention surveys trends! and is the main agency concerned
with protecting the public from disease and controlling spread on a national level. The &ublic 1ealth (epartment
wors at a local level to prevent spread of disease. The (epartment of 1omeland Security would be involved because of concern over potential bioterrorism. The World 1ealth 2rgani3ation would not be involved unless
there were concern about spread of the disease to other parts of the world. The (rug +nforcement Agency contro
use of controlled medication! but would not be involved in an infection outbrea.)amont! 'iedringhous! Comprehensive Nursing Care *nd +dition ,pdate Test -an
Rationa%e /# The Centers for (isease Control and &revention surveys trends! and is the main agency concernedwith protecting the public from disease and controlling spread on a national level. The &ublic 1ealth (epartment
wors at a local level to prevent spread of disease. The (epartment of 1omeland Security would be involved
because of concern over potential bioterrorism. The World 1ealth 2rgani3ation would not be involved unlessthere were concern about spread of the disease to other parts of the world. The (rug +nforcement Agency contro
use of controlled medication! but would not be involved in an infection outbrea.
)earning -ut"ome: (efine infectious and communicable diseases and name agencies that try to control theirspread.
Question
Type: MCSA
A client is admitted with pneumonia and endocarditis. (uring admission! the nurse inserts an indwelling urinary
catheter and administers 5 fluids. The 5 infiltrates and causes a locali3ed thrombophlebitis. After discharge! the
client reports symptoms diagnosed as a urinary tract infection attributed to the indwelling urinary catheter. Which
of these diagnoses would be considered a healthcare$associated infection?
1. &neumonia
2. +ndocarditis
. ,rinary tract infection
!. Thrombophlebitis
Corre"t #ns$er:
Rationa%e 1# A healthcare$associated infection is an infection created by health care delivery. The client6s urinary
tract infection resulted from the indwelling catheter. The client was admitted with pneumonia and endocarditis! sothese were not health care$induced. Thrombophlebitis is not an infection but an inflammation of a blood vessel.
Rationa%e 2# A healthcare$associated infection is an infection created by health care delivery. The client6s urinary
tract infection resulted from the indwelling catheter. The client was admitted with pneumonia and endocarditis! sothese were not health care$induced. Thrombophlebitis is not an infection but an inflammation of a blood vessel.
Rationa%e # A healthcare$associated infection is an infection created by health care delivery. The client6s urinarytract infection resulted from the indwelling catheter. The client was admitted with pneumonia and endocarditis! so
these were not health care$induced. Thrombophlebitis is not an infection but an inflammation of a blood vessel.
)amont! 'iedringhous! Comprehensive Nursing Care *nd +dition ,pdate Test -an
Rationa%e !# A healthcare$associated infection is an infection created by health care delivery. The client6s urinarytract infection resulted from the indwelling catheter. The client was admitted with pneumonia and endocarditis! so
these were not health care$induced. Thrombophlebitis is not an infection but an inflammation of a blood vessel.
&%o'a% Rationa%e:
Cogniti(e )e(e%: Analy3ing
C%ient Need: Safe +ffective Care +nvironmentC%ient Need *u':
)earning -ut"ome: (efine types of infection! including nosocomial infection.
Question !
Type: MCSA
The nurse woring in an acute care facility would be concerned that which of the following clients would be at
greatest ris for infection?
1. A $year$old client who is the C+2 of a ban
2. A *4$year$old client who is pregnant
. A 74$year$old client recovering from a diabetic wound
!. A 7$year$old client with a broen leg
Corre"t #ns$er:
Rationa%e 1# The diabetic client is at greatest ris for infection because diabetes lowers the client6s immuneresponse! as well as because of her age. As we age! immune response declines. The *4$year$old and the C+2 of
the ban would be at lowest ris! while the 7$year$old would be at greater ris because younger people have
reduced immune response due to lac of e8posure to allow development of antigens.
Rationa%e 2# The diabetic client is at greatest ris for infection because diabetes lowers the client6s immuneresponse! as well as because of her age. As we age! immune response declines. The *4$year$old and the C+2 of
the ban would be at lowest ris! while the 7$year$old would be at greater ris because younger people have
reduced immune response due to lac of e8posure to allow development of antigens.
Rationa%e # The diabetic client is at greatest ris for infection because diabetes lowers the client6s immune
response! as well as because of her age. As we age! immune response declines. The *4$year$old and the C+2 ofthe ban would be at lowest ris! while the 7$year$old would be at greater ris because younger people have
reduced immune response due to lac of e8posure to allow development of antigens.
Rationa%e !# The diabetic client is at greatest ris for infection because diabetes lowers the client6s immune
response! as well as because of her age. As we age! immune response declines. The *4$year$old and the C+2 of
the ban would be at lowest ris! while the 7$year$old would be at greater ris because younger people have
reduced immune response due to lac of e8posure to allow development of antigens.
)amont! 'iedringhous! Comprehensive Nursing Care *nd +dition ,pdate Test -an
)earning -ut"ome: dentify factors that increase client ris of infection.
Question /
Type: MCSA
The nurse is woring with a 9$year$old child who has a respiratory infection. The nurse teaches the child to use a
tissue and cover the mouth when coughing in order to brea what lin in the chain of infection?
1. Transmission of the disease
2. &ortal of entry
. )eservoir
!. Susceptible host
Corre"t #ns$er: 0
Rationa%e 1# Covering the mouth during coughing prevents the method of transmission for a cold virus. The
portal of entry is the means of getting into a host:through the nose! in this case. The reservoir is the place where
the organism naturally lives. The client6s susceptibility is her lielihood of becoming ill if e8posed to a virus! andis not altered by covering the mouth.
Rationa%e 2# Covering the mouth during coughing prevents the method of transmission for a cold virus. The
portal of entry is the means of getting into a host:through the nose! in this case. The reservoir is the place where
the organism naturally lives. The client6s susceptibility is her lielihood of becoming ill if e8posed to a virus! andis not altered by covering the mouth.
Rationa%e # Covering the mouth during coughing prevents the method of transmission for a cold virus. The
portal of entry is the means of getting into a host:through the nose! in this case. The reservoir is the place where
the organism naturally lives. The client6s susceptibility is her lielihood of becoming ill if e8posed to a virus! andis not altered by covering the mouth.
Rationa%e !# Covering the mouth during coughing prevents the method of transmission for a cold virus. The portal of entry is the means of getting into a host:through the nose! in this case. The reservoir is the place where
the organism naturally lives. The client6s susceptibility is her lielihood of becoming ill if e8posed to a virus! andis not altered by covering the mouth.
&%o'a% Rationa%e:
Cogniti(e )e(e%: Analy3ing
)amont! 'iedringhous! Comprehensive Nursing Care *nd +dition ,pdate Test -an
)earning -ut"ome: 'ame si8 lins in the chain of infection.
Question
Type: MCSA
The nurse e8amines the client6s postoperative wound and finds it is red! warm to touch! and edematous. The nurse
interprets this to mean the wound is in the#
1. nflammatory stage of wound healing.
2. +8udate stage of wound healing.
. )eparative stage of wound healing.
!. &re$inflammatory stage of wound healing.
Corre"t #ns$er: 0
Rationa%e 1# The first stage of the inflammatory response is characteri3ed by redness! warmth! and swelling
because of increased blood supply to the area. The second phase is characteri3ed by drainage as phagocytic cellsattempt to remove microorganisms from the wound. The third stage is the reparative phase! where swelling and
redness are gone and new tissue begins to form. There is no such thing as the pre$inflammatory stage.
Rationa%e 2# The first stage of the inflammatory response is characteri3ed by redness! warmth! and swelling
because of increased blood supply to the area. The second phase is characteri3ed by drainage as phagocytic cells
attempt to remove microorganisms from the wound. The third stage is the reparative phase! where swelling andredness are gone and new tissue begins to form. There is no such thing as the pre$inflammatory stage.
Rationa%e # The first stage of the inflammatory response is characteri3ed by redness! warmth! and swelling
because of increased blood supply to the area. The second phase is characteri3ed by drainage as phagocytic cellsattempt to remove microorganisms from the wound. The third stage is the reparative phase! where swelling and
redness are gone and new tissue begins to form. There is no such thing as the pre$inflammatory stage.
Rationa%e !# The first stage of the inflammatory response is characteri3ed by redness! warmth! and swelling
because of increased blood supply to the area. The second phase is characteri3ed by drainage as phagocytic cellsattempt to remove microorganisms from the wound. The third stage is the reparative phase! where swelling and
redness are gone and new tissue begins to form. There is no such thing as the pre$inflammatory stage.
)earning -ut"ome: Compare nonspecific and specific defense systems of the body.
Question
Type: MCMA
While the nurse is caring for a client with a methicillin$resistant Staphylococcus aureus wound infection! the
client ass the nurse what causes resistance of bacteria. The nurse6s best response includes which of the
following? Select all that apply.
*tandard Tet: Select all that apply.
1. Taing antibiotics for viral infections when they have no impact
2. ;ailing to finish the entire course of prescribed antibiotics
. (elayed reporting of infected wounds
!. nade<uate immune response
/. ;ailure to create new antibiotics in the 0=>/s
Corre"t #ns$er: 0!*!9
Rationa%e 1# -acteria resistant to antibiotics results from misuse! abuse! and incomplete treatment with
antibiotics. The bacteria that survive after inade<uate antibiotic treatment learn to replicate in a way that maes
them unaffected by the antibiotic! thus becoming a resistant bacteria. (elayed reporting of infections and
inade<uate immune response might mae an infection worse and harder to treat! but this is not a factor in bacteriaresistance. n the 0=>/s! drug companies were not developing new antibiotics which led to natural resistance of
bacteria to antibiotics.
Rationa%e 2# -acteria resistant to antibiotics results from misuse! abuse! and incomplete treatment withantibiotics. The bacteria that survive after inade<uate antibiotic treatment learn to replicate in a way that maes
them unaffected by the antibiotic! thus becoming a resistant bacteria. (elayed reporting of infections and
inade<uate immune response might mae an infection worse and harder to treat! but this is not a factor in bacteria
resistance. n the 0=>/s! drug companies were not developing new antibiotics which led to natural resistance of bacteria to antibiotics.
Rationa%e # -acteria resistant to antibiotics results from misuse! abuse! and incomplete treatment with
antibiotics. The bacteria that survive after inade<uate antibiotic treatment learn to replicate in a way that maes
them unaffected by the antibiotic! thus becoming a resistant bacteria. (elayed reporting of infections andinade<uate immune response might mae an infection worse and harder to treat! but this is not a factor in bacteria
resistance. n the 0=>/s! drug companies were not developing new antibiotics which led to natural resistance of
bacteria to antibiotics.
Rationa%e !# -acteria resistant to antibiotics results from misuse! abuse! and incomplete treatment with
antibiotics. The bacteria that survive after inade<uate antibiotic treatment learn to replicate in a way that maes
them unaffected by the antibiotic! thus becoming a resistant bacteria. (elayed reporting of infections and
)amont! 'iedringhous! Comprehensive Nursing Care *nd +dition ,pdate Test -an
inade<uate immune response might mae an infection worse and harder to treat! but this is not a factor in bacteriaresistance. n the 0=>/s! drug companies were not developing new antibiotics which led to natural resistance of
bacteria to antibiotics.
Rationa%e /# -acteria resistant to antibiotics results from misuse! abuse! and incomplete treatment with
antibiotics. The bacteria that survive after inade<uate antibiotic treatment learn to replicate in a way that maesthem unaffected by the antibiotic! thus becoming a resistant bacteria. (elayed reporting of infections and
inade<uate immune response might mae an infection worse and harder to treat! but this is not a factor in bacteriaresistance. n the 0=>/s! drug companies were not developing new antibiotics which led to natural resistance of bacteria to antibiotics.
)earning -ut"ome: (escribe drug$resistant organisms! as well as nursing care and client teaching for them.
Question
Type: MCSA
While preparing a sterile field! the nurse accidentally contaminates the field through which of the following?
1. ,sing sterile forceps to move items on the sterile tray
2. 2pening the flaps of the sterile tray toward the nurse! then the sides! then away
. Touching a one$inch margin on the sterile wrapper
!. Ad%usting the bedside table above the waist prior to opening the tray
Corre"t #ns$er: *
Rationa%e 1# t is improper to reach across a sterile field! so the flaps should always be opened toward the nurse!and the nurse should move around the tray to prevent reaching across it. The remaining options demonstrate
correct techni<ue.
Rationa%e 2# t is improper to reach across a sterile field! so the flaps should always be opened toward the nurse!
and the nurse should move around the tray to prevent reaching across it. The remaining options demonstratecorrect techni<ue.
Rationa%e # t is improper to reach across a sterile field! so the flaps should always be opened toward the nurse!
and the nurse should move around the tray to prevent reaching across it. The remaining options demonstratecorrect techni<ue.
)amont! 'iedringhous! Comprehensive Nursing Care *nd +dition ,pdate Test -an
Rationa%e !# t is improper to reach across a sterile field! so the flaps should always be opened toward the nurse!and the nurse should move around the tray to prevent reaching across it. The remaining options demonstrate
correct techni<ue.
&%o'a% Rationa%e:
Cogniti(e )e(e%: Applying
C%ient Need: Safe +ffective Care +nvironmentC%ient Need *u':
)earning -ut"ome: dentify important means of controlling microorganisms in the environment.
Question 3
Type: MCMA
The nurse would wear gloves while bathing a client in which of the following circumstances? Select all that apply
*tandard Tet: Select all that apply.
1. When cleaning the client6s dentures
2. When washing the perineum of a continent client
. When washing the bac and providing a bac rub
!. When changing the client6s linen
/. When washing the e8tremities
Corre"t #ns$er: 0!*
Rationa%e 1# The nurse wears gloves to protect against contamination from secretions! liely to be found when
cleaning dentures and washing the perineum! whether the client is continent or incontinent. There is no need towear gloves when washing the bac! giving a bac rub! changing linens! or washing the client6s bac unless the
client has an open wound or there is drainage on the linen! which is not indicated in this <uestion.
Rationa%e 2# The nurse wears gloves to protect against contamination from secretions! liely to be found when
cleaning dentures and washing the perineum! whether the client is continent or incontinent. There is no need towear gloves when washing the bac! giving a bac rub! changing linens! or washing the client6s bac unless the
client has an open wound or there is drainage on the linen! which is not indicated in this <uestion.
Rationa%e # The nurse wears gloves to protect against contamination from secretions! liely to be found when
cleaning dentures and washing the perineum! whether the client is continent or incontinent. There is no need towear gloves when washing the bac! giving a bac rub! changing linens! or washing the client6s bac unless the
client has an open wound or there is drainage on the linen! which is not indicated in this <uestion.
)amont! 'iedringhous! Comprehensive Nursing Care *nd +dition ,pdate Test -an
Rationa%e !# The nurse wears gloves to protect against contamination from secretions! liely to be found whencleaning dentures and washing the perineum! whether the client is continent or incontinent. There is no need to
wear gloves when washing the bac! giving a bac rub! changing linens! or washing the client6s bac unless the
client has an open wound or there is drainage on the linen! which is not indicated in this <uestion.
Rationa%e /# The nurse wears gloves to protect against contamination from secretions! liely to be found whencleaning dentures and washing the perineum! whether the client is continent or incontinent. There is no need to
wear gloves when washing the bac! giving a bac rub! changing linens! or washing the client6s bac unless theclient has an open wound or there is drainage on the linen! which is not indicated in this <uestion.
)earning -ut"ome: (escribe Standard &recautions and Transmission$based &recautions as well as C(C
uidelines.
Question 10
Type: MCSA
The nurse is assisting with data collection for a <uality assurance study to monitor correct techni<ue when e8iting
an airborne isolation room. The nurse commends which of the following staff for performing proper techni<ue?
1. The respiratory therapist removes mas! gown! and then gloves.
2. The houseeeper removes gloves! mas! then gown.
. The physician removes gloves! then gown! and unties the top string of the mas! allowing it to hang around his
nec.
!. The nurse removes gloves! washes hands! then removes gown and mas.
Corre"t #ns$er: *
Rationa%e 1# loves are removed first! taing care not to touch the sin with the contaminated side of thematerial! then the mas is removed! and finally the gown is removed. After all e<uipment is removed! hand
hygiene should be performed. f the gown and mas are touched after hand hygiene is performed! the hands are
contaminated by touching the contaminated e<uipment. t is never appropriate to allow a used mas to remainhanging around the nec.
Rationa%e 2# loves are removed first! taing care not to touch the sin with the contaminated side of the
material! then the mas is removed! and finally the gown is removed. After all e<uipment is removed! hand
hygiene should be performed. f the gown and mas are touched after hand hygiene is performed! the hands arecontaminated by touching the contaminated e<uipment. t is never appropriate to allow a used mas to remain
hanging around the nec.
)amont! 'iedringhous! Comprehensive Nursing Care *nd +dition ,pdate Test -an
Rationa%e # loves are removed first! taing care not to touch the sin with the contaminated side of thematerial! then the mas is removed! and finally the gown is removed. After all e<uipment is removed! hand
hygiene should be performed. f the gown and mas are touched after hand hygiene is performed! the hands are
contaminated by touching the contaminated e<uipment. t is never appropriate to allow a used mas to remainhanging around the nec.
Rationa%e !# loves are removed first! taing care not to touch the sin with the contaminated side of the
material! then the mas is removed! and finally the gown is removed. After all e<uipment is removed! handhygiene should be performed. f the gown and mas are touched after hand hygiene is performed! the hands arecontaminated by touching the contaminated e<uipment. t is never appropriate to allow a used mas to remain
)earning -ut"ome: (escribe Standard &recautions and Transmission$based &recautions as well as C(Cuidelines.
Question 11
Type: MCSA
The nurse has been newly hired onto a respiratory unit with si8 negative pressure isolation rooms for clients with
infections passed by respiratory aerosols! such as SA)S or tuberculosis. -efore the nurse can care for clients in
these rooms! what must happen?
1. The nurse must be tested for tuberculosis.
2. The nurse must be fitted for a '=9 respirator.
. The nurse must attend a class on negative pressure isolation.
!. The nurse will not care for these types of clients.
Corre"t #ns$er: *
Rationa%e 1# -ecause these conditions are spread through aerosoli3ed secretions! it is important that the nurse
wear a well$fitted mas that will not allow any of the particles to enter the lungs! so the nurse will need to be fittefor an '=9 respirator mas that will be tested to assure a good fit before the nurse can care for these clients.
Testing for tuberculosis is part of the hiring process! and the nurse already nows about negative pressureisolation.
Rationa%e 2# -ecause these conditions are spread through aerosoli3ed secretions! it is important that the nurse
wear a well$fitted mas that will not allow any of the particles to
)amont! 'iedringhous! Comprehensive Nursing Care *nd +dition ,pdate Test -an
Rationa%e # -ecause these conditions are spread through aerosoli3ed secretions! it is important that the nursewear a well$fitted mas that will not allow any of the particles to enter the lungs! so the nurse will need to be fitte
for an '=9 respirator mas that will be tested to assure a good fit before the nurse can care for these clients.
Testing for tuberculosis is part of the hiring process! and the nurse already nows about negative pressureisolation.
Rationa%e !# -ecause these conditions are spread through aerosoli3ed secretions! it is important that the nurse
wear a well$fitted mas that will not allow any of the particles to enter the lungs! so the nurse will need to be fittefor an '=9 respirator mas that will be tested to assure a good fit before the nurse can care for these clients.Testing for tuberculosis is part of the hiring process! and the nurse already nows about negative pressure
)earning -ut"ome: 'ame e<uipment used for infection control.
Question 12
Type: MCSA
The nurse is caring for a client admitted with a diagnosis of appendicitis. The client has a history of idney
transplant! and taes immune$suppressing medications to prevent organ re%ection. Which of the following nursing
diagnoses would be most appropriate for this client postoperatively?
1. nfection! ris for! related to nutritional deficit
2. nfection! ris for! related to overhydration
. nfection! ris for! related to immunosuppression
!. nfection! ris for! related to postoperative wound
Corre"t #ns$er:
Rationa%e 1# This client is at ris due to immunosuppression and an inade<uate immune response to pathogens.
While the postoperative wound might be the pathogens6 easiest entry point! infection could occur because of the
client6s 5 site! airway! or any other entry point! so the immune suppression is the primary concern! creating asusceptible host. 'utritional and hydration status are unnown.
Rationa%e 2# This client is at ris due to immunosuppression and an inade<uate immune response to pathogens.While the postoperative wound might be the pathogens6 easiest entry point! infection could occur because of the
client6s 5 site! airway! or any other entry point! so the immune suppression is the primary concern! creating a
susceptible host. 'utritional and hydration status are unnown.
)amont! 'iedringhous! Comprehensive Nursing Care *nd +dition ,pdate Test -an
Rationa%e # This client is at ris due to immunosuppression and an inade<uate immune response to pathogens.While the postoperative wound might be the pathogens6 easiest entry point! infection could occur because of the
client6s 5 site! airway! or any other entry point! so the immune suppression is the primary concern! creating a
susceptible host. 'utritional and hydration status are unnown.
Rationa%e !# This client is at ris due to immunosuppression and an inade<uate immune response to pathogens.While the postoperative wound might be the pathogens6 easiest entry point! infection could occur because of the
client6s 5 site! airway! or any other entry point! so the immune suppression is the primary concern! creating asusceptible host. 'utritional and hydration status are unnown.
&%o'a% Rationa%e:
Cogniti(e )e(e%: Analy3ing
C%ient Need: @C'Safe +ffective Care +nvironmentB &hysiological ntegrity
)earning -ut"ome: ist relevant nursing diagnoses and interventions for clients with an infection or at ris of
developing an infection.
Question 1
Type: MCSA
The nurse! while caring for a client with yme disease! e8plains the concept of method of transmission of the
disease when e8plaining which of the following?
1. "t comes from an infected tic."
2. "When the infected tic connects with your circulatory system! the infection is passed to you."
. "-ecause you weren6t feeling well! when the tic attached! you were more liely to become infected."
!. "Washing your hands would reduce the ris of becoming infected from the tic."
Corre"t #ns$er: 0
Rationa%e 1# The tic6s infecting the client is an e8ample of a vector$borne method of transmission. The
connection to the circulatory system allowing the infection to pass into the client is the portal of entry. f the clienwasn6t feeling well! this would increase the susceptibility of the host. Washing hands would have no impact on
reducing the ris of a tic! and would demonstrate the concept of a reservoir of other types of infection.
Rationa%e 2# The tic6s infecting the client is an e8ample of a vector$borne method of transmission. The
connection to the circulatory system allowing the infection to pass into the client is the portal of entry. f the clienwasn6t feeling well! this would increase the susceptibility of the host. Washing hands would have no impact on
reducing the ris of a tic! and would demonstrate the concept of a reservoir of other types of infection.
Rationa%e # The tic6s infecting the client is an e8ample of a vector$borne method of transmission. The
connection to the circulatory system allowing the infection to pass into the client is the portal of entry. f the clien
)amont! 'iedringhous! Comprehensive Nursing Care *nd +dition ,pdate Test -an
wasn6t feeling well! this would increase the susceptibility of the host. Washing hands would have no impact onreducing the ris of a tic! and would demonstrate the concept of a reservoir of other types of infection.
Rationa%e !# The tic6s infecting the client is an e8ample of a vector$borne method of transmission. The
connection to the circulatory system allowing the infection to pass into the client is the portal of entry. f the clien
wasn6t feeling well! this would increase the susceptibility of the host. Washing hands would have no impact onreducing the ris of a tic! and would demonstrate the concept of a reservoir of other types of infection.
Rationa%e /# The fourth lin in the chain of infection is a method! or mode! of transmissionB the three modes oftransmission are direct contact! indirect contact! and droplet or airborne transmission.
Rationa%e # The fifth lin in the chain of infection is a portal of entry into the hoseB broen sin provides a porta
of entryB most pathogens enter the body through the same routes they use to leave it.
(uring admission to the facility! the nurse will loo at factors that reduce the bodyFs immune system. The 4>$yearold e8ecutive with diabetes would demonstrate which of the following ris factors?
*tandard Tet: Select all that apply.
1. Age
2. Stressors
. 'utrition
!. Medications
/. Chronic diseases
Corre"t #ns$er: *!9
Rationa%e 1# The very young and very old are at ris.
Rationa%e 2# &hysical and emotional stressors can influence susceptibility to infection. 1is e8ecutive position
could be identified as a stressor.
Rationa%e # We have no information regarding his nutrition status.
Rationa%e !# 'o information is given regarding medications.
Rationa%e /# A chronic disease such as diabetes could increase susceptibility to disease.
Rationa%e 1# The third lin in the chain is the portal of e8it! a way of leaving the reservoirB any body fluid can
provide an e8it from the source.
Rationa%e 2# The si8th lin in the chain of infection is the susceptibility of the hostB a compromised host issomeone who has a higher ris for getting an infection for one or more reasons.
Rationa%e # The second lin in the chain of infection is the place where the microorganism naturally lives! its
reservoirB this can be the individual! other humans! animals! plants! insects! birds! or the environment.
Rationa%e !# The first lin in the chain of infection is the etiologic agent! or the source of infection.
Rationa%e /# The fourth lin in the chain of infection is a method! or mode! of transmissionB the three modes oftransmission are direct contact! indirect contact! and droplet or airborne transmission.
Rationa%e # The fifth lin in the chain of infection is a portal of entry into the hostB broen sin provides a porta
of entryB most pathogens enter the body through the same routes they use to leave it.
When removing soiled protective e<uipment! the nurse is careful to follow a specific order of actions. ist thefollowing in the correct order to maintain infection control#
*tandard Tet: Clic and drag the options below to move them up or down.
Choi"e 1. )emove any eyewear.
Choi"e 2. )emove the mas.
Choi"e . Wash hands and wrists.
Choi"e !. )emove the gown.
Choi"e /. )emove gloves.
Corre"t #ns$er: 4!*!9!!0
Rationa%e 1# ;inally! remove any eyewear.
Rationa%e 2# After removing the gloves! remove the mas! holding it by the strings.
Rationa%e # Wash the hands and wrists thoroughly.
Rationa%e !# )emove the gown ne8t.
Rationa%e /# )emove the gloves firstB if the gown is tied in the front! undo the ties before removing the gloves.
)amont! 'iedringhous! Comprehensive Nursing Care *nd +dition ,pdate Test -an