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Chapter 27 and 32

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Infection and Inflammation

Pregunta 1 de 37

1

What are the smallest infectious agents capable of causing an infection?

Selecciona una de las siguientes respuestas posibles:

  • Bacteria

  • Viruses

  • Molds

  • Yeasts

Explicación

Pregunta 2 de 37

1

Your patient has developed a low-grade fever and states that she has felt very tired lately. You interpret these findings as indicating which stage of infection?

Selecciona una de las siguientes respuestas posibles:

  • Incubation period

  • Prodromal stage

  • Full stage of illness

  • Convalescent period

Explicación

Pregunta 3 de 37

1

Efforts by healthcare facilities to reduce the incidence of HAIs include an awareness of which of the following?

Selecciona una de las siguientes respuestas posibles:

  • The CDC requires all states to report HAI rates from each hospital.

  • The gastrointestinal tract is a common site for HAIs.

  • Joint Commission considers death or serious injury from HAIs a sentinel event

  • The causal agent for most HAIs is viral.

Explicación

Pregunta 4 de 37

1

A patient develops a urinary tract infection after an indwelling urinary catheter has been inserted. This would most accurately be termed as which type of infection?

Selecciona una de las siguientes respuestas posibles:

  • A viral infection

  • A chronic infection

  • An iatrogenic infection

  • An opportunistic infection

Explicación

Pregunta 5 de 37

1

The nurse has opened the sterile supplies and donned two sterile gloves to complete a sterile dressing change, a procedure that requires surgical asepsis. The nurse must do which of the following?

Selecciona una de las siguientes respuestas posibles:

  • Keep splashes on the sterile field to a minimum

  • Cover the nose and mouth with gloved hands if a sneeze is imminent

  • Use forceps soaked in disinfectant

  • Consider the outer 1 inch of the sterile field as contaminated

Explicación

Pregunta 6 de 37

1

The CDC standard precaution recommendations apply to which of the following?

Selecciona una de las siguientes respuestas posibles:

  • Only patients with diagnosed infections

  • Only blood and body fluids with visible blood

  • All body fluids including sweat

  • All patients receiving care in hospitals

Explicación

Pregunta 7 de 37

1

In addition to standard precautions, the nurse caring for a patient with rubella would plan to implement what type of precautions?

Selecciona una de las siguientes respuestas posibles:

  • Droplet precautions

  • Airborne precautions

  • Contact precautions

  • Universal precautions

Explicación

Pregunta 8 de 37

1

When caring for a patient with latex allergy, the nurse creates a latex-safe environment by doing which of the following?

Selecciona una de las siguientes respuestas posibles:

  • Carefully cleaning the wall-mounted blood pressure device before using it

  • Donning latex gloves outside the room to limit powder dispersal

  • Using a latex-free pharmacy protocol

  • Placing the patient in a semiprivate room

Explicación

Pregunta 9 de 37

1

Which organization(s) initially developed the guidelines for minimum protection standards for infection prevention and control?

Selecciona una de las siguientes respuestas posibles:

  • OSHA

  • Individual healthcare facilities

  • The state governing body

  • The CDC

Explicación

Pregunta 10 de 37

1

Which of the following lists the recommended sequence for removing soiled personal protective equipment when the nurse prepares to leave the patient’s room?

Selecciona una de las siguientes respuestas posibles:

  • Gown, goggles, mask, gloves, and exit the room

  • Gloves, wash hands, remove gown, mask, and goggles

  • Gloves, goggles, gown, mask, and wash hands

  • Goggles, mask, gloves, gown, and wash hands

Explicación

Pregunta 11 de 37

1

For a nurse under normal conditions with unsoiled hands, effective hand hygiene between patients requires which of the following?

Selecciona una de las siguientes respuestas posibles:

  • At least a 15-second scrub with plain soap and water

  • At least a 23-minute scrub with an antimicrobial soap

  • Use of an alcohol-based antiseptic handrub

  • That a mask be worn when scrubbing

Explicación

Pregunta 12 de 37

1

Which hospitalized patient is most at risk for developing a healthcare-associated infection?

Selecciona una de las siguientes respuestas posibles:

  • Mr. Y, a 60-year-old patient who smokes two packs of cigarettes daily

  • Mrs. J, a 40-year-old patient who has a white blood cell count of 6,000/mm3

  • Mr. L, a 65-year-old patient who has an indwelling urinary catheter in place

  • Mrs. M, a 60-year-old patient who is a vegetarian and slightly underweight

Explicación

Pregunta 13 de 37

1

A patient develops food poisoning from contaminated potato salad. What is the means of transmission for the infecting organism?

Selecciona una de las siguientes respuestas posibles:

  • Direct contact

  • Vector

  • Vehicle

  • Airborne

Explicación

Pregunta 14 de 37

1

A nurse is caring for an obese 62-year-old patient with arthritis who has developed an open reddened area over his sacrum. Which of the following is a priority nursing diagnosis?

Selecciona una de las siguientes respuestas posibles:

  • Imbalanced Nutrition: More Than Body Requirements related to immobility

  • Impaired Physical Mobility related to pain and discomfort

  • Chronic Pain related to immobility

  • Risk for Infection related to altered skin integrity

Explicación

Pregunta 15 de 37

1

The nurse teaches a patient at home to use clean technique when changing a wound dressing. This is which of the following?

Selecciona una de las siguientes respuestas posibles:

  • The nurse's preference

  • Safe for the home setting

  • Unethical behavior

  • Grossly negligent

Explicación

Pregunta 16 de 37

1

Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and generalized malaise, as well as pain and redness at the surgical site. Which intervention is most important to include in this patient’s nursing care plan?

Selecciona una de las siguientes respuestas posibles:

  • Document the findings and continue to monitor the patient.

  • Administer antipyretics, as ordered.

  • Increase the frequency of assessment to every hour and notify the patient’s physician.

  • Increase the frequency of wound care and contact the physician for an antibiotic order.

Explicación

Pregunta 17 de 37

1

Which term would the nurse use to document wound drainage that is thick, odorous, and green?

Selecciona una de las siguientes respuestas posibles:

  • Serous

  • Sanguineous

  • Serosanguineous

  • Purulent

Explicación

Pregunta 18 de 37

1

A patient, age 16, was in an automobile accident and received a wound across her nose and cheek. After surgery to repair the wound, the patient says, “I am so ugly now.” Based on this statement, what nursing diagnosis would be most appropriate?

Selecciona una de las siguientes respuestas posibles:

  • Pain

  • Impaired skin integrity

  • Disturbed body image

  • Disturbed thought process

Explicación

Pregunta 19 de 37

1

A patient is admitted with a nonhealing surgical wound. Which nursing action is most effective in preventing a wound infection?

Selecciona una de las siguientes respuestas posibles:

  • Using sterile dressing supplies

  • Suggesting dietary supplements

  • Applying antibiotic ointment

  • Performing careful hand hygiene

Explicación

Pregunta 20 de 37

1

During a dressing change, inspection of the wound reveals what appears to be reddish-pink tissue in the wound. The nurse interprets this as most likely indicating:

Selecciona una de las siguientes respuestas posibles:

  • A sign of infection

  • Eschar

  • Exudate

  • Granulation tissue

Explicación

Pregunta 21 de 37

1

The nurse is performing a sterile irrigation of an open abdominal wound. Which intervention should be done first?

Selecciona una de las siguientes respuestas posibles:

  • Direct a stream of solution into the wound.

  • Position the patient so the irrigation solution will flow from clean to dirty.

  • Assess the wound and surrounding tissue.

  • Put on sterile gloves.

Explicación

Pregunta 22 de 37

1

The nurse is developing a plan of care for an 86-year-old woman who has been admitted for right hip arthroplasty (hip replacement). Which assessment finding(s) indicate a high risk for pressure ulcer development for this patient? Select all that apply.

Selecciona una o más de las siguientes respuestas posibles:

  • The patient takes time to think about her responses to questions.

  • The patient’s age of 86 years.

  • Patient reports inability to control urine.

  • A scheduled hip arthroplasty

  • Lab findings include BUN 12 (elderly normal 8-23 mg/dL) and creatinine 0.9 (adult female normal 0.61.1 mg/dL).

  • Patient reports increased pain in right hip when repositioning in bed or chair.

Explicación

Pregunta 23 de 37

1

The nurse is explaining to a patient the anticipated effect of the application of cold to an injured area. What response indicates the patient understands the explanation?

Selecciona una de las siguientes respuestas posibles:

  • “I can expect to have more discomfort in the area where the cold is applied.”

  • “I should expect more drainage from the incision after the ice has been in place.”

  • “I should see less swelling and redness with the cold treatment.”

  • “My incision may bleed more when the ice is first applied.”

Explicación

Pregunta 24 de 37

1

The nurse is providing patient teaching regarding the use of negative pressure wound therapy. Which explanation provides the most accurate information to the patient?

Selecciona una de las siguientes respuestas posibles:

  • The therapy is used to collect excess blood loss and prevent the formation of a scab.

  • The therapy will prevent infection, ensuring the wound heals with less scar tissue.

  • The therapy provides a moist environment and stimulates blood flow to the wound.

  • The therapy irrigates the wound to keep it free from debris and excess wound fluid.

Explicación

Pregunta 25 de 37

1

After an initial assessment, the nurse documents the presence of a reddened area that has blistered. According to recognized staging systems, as what stage would this ulcer be classified?

Selecciona una de las siguientes respuestas posibles:

  • Stage 1

  • Stage 2

  • Stage 3

  • Stage 4

Explicación

Pregunta 26 de 37

1

An older confused patient sits and slumps in her chair most of the day. She is most likely to develop a pressure ulcer because of what factor?

Selecciona una de las siguientes respuestas posibles:

  • Malnutrition

  • Shearing forces

  • Edema

  • A chronic disease

Explicación

Pregunta 27 de 37

1

The nurse assesses a stage III pressure ulcer manifested as:

Selecciona una de las siguientes respuestas posibles:

  • Redness that persists when pressure is relieved

  • An open lesion with full thickness tissue loss and visible subcutaneous fat

  • A necrotic area extending through the fascia to bone

  • A reddened area with an abrasion and pain

Explicación

Pregunta 28 de 37

1

Which action would be a priority in preventing a patient from developing a pressure ulcer?

Selecciona una de las siguientes respuestas posibles:

  • Using waterproof material on the bed

  • Massaging any reddened area frequently

  • Using an air-inflated ring to relieve pressure on areas

  • Using a mild cleansing agent when cleansing the skin

Explicación

Pregunta 29 de 37

1

A nurse is assessing a patient in the resolution stage of an infection. The nurse would anticipate

Selecciona una de las siguientes respuestas posibles:

  • Vague, non specific signs and symptoms of early stages of infection.

  • Full presense of signs and symptoms anticipated with an infection.

  • No symptoms. This would be the interval between invasion of pathogens and the appearance of symptoms.

  • A period of recovery. Signs and symptoms disappear and the person returns to a healthy state.

Explicación

Pregunta 30 de 37

1

A patient is 7 days post operative. Which stage of the wound healing process is the patient most likely experiencing currently?

Selecciona una de las siguientes respuestas posibles:

  • Reconstruction or Proliferative Phase.

  • Remodeling or Maturation Phase

  • Inflammatory Phase

  • Hemostasis Phase

Explicación

Pregunta 31 de 37

1

As a nurse knowledgeable about the chain of infection, you are concerned with reducing reservoirs which are necessary for an infection to develop. A way to reduce reservoirs would include to

Selecciona una de las siguientes respuestas posibles:

  • Wear gloves and other personal protective wear when caring for the patient.

  • Wash hands, use antiseptics and disinfectants.

  • Empty the foley catheter bag regularly and keep the bag below bladder level.

  • Instruct the patient to cover his nose and mouth when sneezing.

Explicación

Pregunta 32 de 37

1

Which nursing action prevents an organism from exiting a reservoir in the chain of infection?

Selecciona una de las siguientes respuestas posibles:

  • Immunizations.

  • Using pesticides.

  • Use of disposible supplies.

  • Prompt, frequent administration of antibiotics.

Explicación

Pregunta 33 de 37

1

A nurse is caring for a patient with a healing wound. The nurse is aware that multiple factors either promote or impede wound healing. Factors that can promote wound healing would include

Selecciona una de las siguientes respuestas posibles:

  • A wound healing by secondary intention.

  • A clean surgical wound healing free of infection.

  • A past history of diabetes mellitus.

  • A past history of immunosuppressive therapy to promote healing.

Explicación

Pregunta 34 de 37

1

A student nurse is teaching a new mother about immunizations. The student nurse knows teaching was effective when the new mother states that immunity acquired from either having the infection or being immunized and developing immunity is known as __________.

Selecciona una de las siguientes respuestas posibles:

  • Active immunity

  • Passive immunity

  • Immune response

  • Tertiary response

Explicación

Pregunta 35 de 37

1

As a nurse, you are aware that the CDC has identified two tiers of precautions to prevent the spread of infection. The second tier, transmission-based precautions includes all of the following except

Selecciona una de las siguientes respuestas posibles:

  • Wearing gloves when emptying a urinal.

  • Wearing a mask when working within 3 feet of the patient.

  • Wearing a gown if in contact with infectious agent.

  • Wearing a specially fitted mask when entering the patient's room.

Explicación

Pregunta 36 de 37

1

A infection control nurse is concerned about the incidence of nosocomial infection in a particular facility. Which of the following would be least likely to place the patient at risk for developing a nosocomial infection?

Selecciona una de las siguientes respuestas posibles:

  • Admission for outpatient surgery.

  • Several invasive treatments while closely monitoring vital signs.

  • Insertion of a foley catheter after surgery.

  • Treatment with broad spectrum antibiotics to ward off nosocomial infection

Explicación

Pregunta 37 de 37

1

The nurse has selected a health problem of risk for infection related to trauma (surgical incision). The behavior outcome that has been written for the patient is for the incision to remain free from signs and symptoms of infection over the next 5 days. The nurse would be alert for clinical cues that the goal might not be met if the patient's assessment reveals which of the following?

Selecciona una de las siguientes respuestas posibles:

  • Wound edges approximated.

  • Redness beyond the edges of the wound.

  • Coolness felt around the wound, no drainage.

  • Decreased edema.

Explicación

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