4. Identify patients at risk Correct answer- The nurse is caring for a group of
hospitalized patients. What should the nurse do first to prevent patient infections?
1. Provide small bedside bags to dispose of used tissues
2. Encourage staff to avoid coughing near patients
3. Administer antibiotics as ordered
4. Identify patients at risk
1. Fever Correct answer- The nurse identifi es that a patient has an infl ammatory
response. Which local patient adaptation supports this conclusion?
1. Fever
2. Erythema
3. Bradypnea
4. Tachycardi
3. Normal saline and apply a wet-to-damp dressing." Correct answer- A patient has a
wound that is healing by secondary intention. To best support healing of the wound, the
nurse should expect the practitioner's order to state, "Clean wound with:
1. Betadine and apply a dry sterile dressing."
2. Normal saline and cover with a gauze dressing."
3. Normal saline and apply a wet-to-damp dressing."
4. Half peroxide and half normal saline and apply a wet to dry dressing."
3. Puncture of the foot by a nail Correct answer- The nurse identifi es that the greatest
risk for a wound infection exists for a patient with a:
1. Surgical creation of a colostomy
2. First-degree burn on the back
3. Puncture of the foot by a nail
4. Paper cut on the finger
1. Cells of the skin are constantly being replaced, thereby eliminating external
pathogens Correct answer- .The nurse understands that the skin protects the body from
infections because the:
1. Cells of the skin are constantly being replaced, thereby eliminating external
pathogens
2. Epithelial cells are loosely compacted on skin, providing a barrier against pathogens
3. Moisture on the skin surface prevents colonization of pathogens
4. Alkalinity of the skin limits the growth of pathogens
,1. Stool for ova and parasites Correct answer- The nurse must collect the following
specimens. Which specimen collection does not require the use of surgical aseptic
technique?
1. Stool for ova and parasites
2. Specimen for a throat culture
3. Urine from a retention catheter
4. Exudate from a wound for culture and sensitivity
2. Contact Correct answer- A patient is positive for Clostridium difficile. The nurse
should institute the isolation precaution known as:
1. Droplet
2. Contact
3. Reverse
4. Airborne
1. Hyperthermia Correct answer- Which patient information collected by the nurse
reflects a systemic adaptation to a wound infection?
1. Hyperthermia
2. Exudate
3. Edema
4. Pain
1. Wash the hands before and after providing care to a patient Correct answer- To
interrupt the transmission link in the chain of infection, the nurse should:
1. Wash the hands before and after providing care to a patient
2. Position a commode next to a patient's bed
3. Provide education about a balanced diet
4. Change a dressing when it is soiled
3. Pneumonia Correct answer- The nurse is providing for the nutrition needs of several
patients. The nurse identifies the need for an increase in caloric intake above average
requirements for the patient who has:
1. Nausea
2. Dysphagia
3. Pneumonia
4. Depression
1. Cuts in the skin from a kitchen knife Correct answer- The nurse is caring for patients
with a variety of wounds. The nurse understands that healing by primary intention most
likely occurs with:
1. Cuts in the skin from a kitchen knife
2. Excoriated perianal areas
3. Abrasions of the skin
4. Pressure ulcers
,3. Harbor microorganisms Correct answer- The primary reason why the nurse should
avoid glued-on artificial nails is because they:
1. Interfere with dexterity of the fingers
2. Could fall off in a patient's bed
3. Harbor microorganisms
4. Can scratch a patient
3. Older adults Correct answer- The nurse understands that subclinical infections most
commonly occur in:
1. Infants
2. Adolescents
3. Older adults
4. Children of school age
3. Burns more than twenty percent of the body Correct answer- The nurse understands
that the factor that places a patient at the greatest risk for developing an infection is:
1. Implantation of a prosthetic device
2. Presence of an indwelling urinary catheter
3. Burns more than twenty percent of the body
4. Multiple puncture sites from laparoscopic surgery
4. Immune response Correct answer- The nurse understands that a secondary line of
defense against infection is the:
1. Mucous membranes of the respiratory tract
2. Urinary tract environment
3. Integumentary system
4. Immune response
2. Administering childhood immunizations Correct answer- Which nursing action
protects the patient as a susceptible host in the chain of infection?
1. Wearing personal protective equipment
2. Administering childhood immunizations
3. Recapping a used needle before discarding
4. Disposing of soiled gloves in a waste container
2. Purulent drainage Correct answer- A patient tells the nurse, "I think I have an ear
infection." The nurse should assess this patient for which objective human response to
an ear infection?
1. Throbbing pain
2. Purulent drainage
3. Dizziness when moving
4. Hearing a buzzing sound
2. Neutrophils Correct answer- The nurse is concerned about a patient's ability to
withstand exposure to pathogens. What blood component should the nurse monitor?
1. Platelets
, 2. Neutrophils
3. Hemoglobin
4. Erythrocytes
1. Tears in the eyes Correct answer- The nurse understands which primary
(nonspecific) defense protects the body from infection?
1. Tears in the eyes
2. Alkalinity of gastric secretions
3. Bile in the gastrointestinal system
4. Moist environment of the epidermis
4. Pediculosis Correct answer- When brushing a patient's hair, the nurse notes white
oval particles attached to the hair behind the ears. The nurse should assess the patient
further for signs of:
1. Scabies
2. Dandruff
3. Hirsutism
4. Pediculosis
4. Phagocytic cells release pyrogens that stimulate the hypothalamus Correct answer-
The nurse understands that a rise in body temperature is associated with the presence
of infection because:
1. Pain activates the sympathetic nervous system
2. Erythema increases the flow of blood throughout the body
3. Leukocyte migration precipitates the inflammatory response
4. Phagocytic cells release pyrogens that stimulate the hypothalamus
4. Wound infection caused by unwashed hands of a caregiver Correct answer- . The
nurse understands that an example of an iatrogenic infection is a:
1. Vaginal infection in a postmenopausal woman
2. Respiratory infection contracted from a grandchild
3. Urinary tract infection in a patient who is sedentary
4. Wound infection caused by unwashed hands of a caregiver
2. Facilitate the healing process Correct answer- The physician orders a wound to be
packed with a wet-to-damp gauze dressing. The nurse understands that this is done
primarily to:
1. Minimize the loss of protein
2. Facilitate the healing process
3. Increase resistance to infection
4. Prevent the entry of microorganisms
3. Cilia in the respiratory tract Correct answer- The nurse understands that a primary
(nonspecific) defense that protects the body from infection is:
1. Antibiotic therapy
2. The high pH of the skin
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