for Patients with Infection
Ignatavicius: Medical-Surgical
Nursing, 11th Edition Test Bank 2025
Updated Set.
The nurse learning about infection discovers that which factor is the best and most important
barrier to infection?
a. Colonization by host bacteria
b. Gastrointestinal secretions
c. Inflammatory processes
d. Skin and mucous membranes - Answer ANS: D
The skin and mucous membranes are two of the most important barriers against infection. The
other options are also barriers, but are considered secondary to skin and mucous membranes.
A nursing manager is concerned about the number of infections on the hospital unit. What
action by the manager would best help prevent these infections?
a. Auditing staff members' hand hygiene practices
b. Ensuring clients are placed in appropriate isolation
c. Establishing a policy to remove urinary catheters quickly
d. Teaching staff members about infection control methods - Answer ANS: A
All methods will help prevent infection; however, health care workers' lack of hand hygiene
is the biggest cause of health care-associated infections. The manager can start with a hand
hygiene audit to see if this is a contributing cause.
An assistive personnel asks why brushing clients' teeth with a toothbrush in the intensive care
unit is important to infection control. What response by the registered nurse is best?
a. "It mechanically removes biofilm on teeth."
b. "It's easier to clean all surfaces with a brush."
c. "Oral care is important to all our clients."
d. "Toothbrushes last longer than oral swabs." - Answer ANS: A
, A client is admitted with possible sepsis. Which action will the nurse perform first?
a. Administer antibiotics.
b. Give an antipyretic.
c. Place the client in isolation.
d. Obtain specified cultures. - Answer ANS: D
Prior to administering antibiotics, the nurse obtains the prescribed cultures. Broad-spectrum
antibiotics will be administered until the culture and sensitivity results are known. Antipyretics
are given if the client is uncomfortable; fever is a defense mechanism. Giving antipyretics does
not occur before obtaining cultures. The client may or may not need isolation.
A client is hospitalized and on multiple antibiotics. The client develops frequent diarrhea. What
action by the nurse is most important?
a. Consult with the primary health care provider about obtaining stool cultures.
b. Delegate frequent perianal care to assistive personnel.
c. Place the client on NPO status until the diarrhea resolves.
d. Request a prescription for an antidiarrheal medication. - Answer ANS: A
Hospitalized clients who have three or more stools a day for 2 or more days are suspected of
having infection with Clostridium difficile. The nurse will inform the primary health care
provider and request stool cultures. Frequent perianal care is important and can be delegated
but is not the most important action. The client does not necessarily need to be NPO; if the
client is NPO, the nurse ensures he or she is getting appropriate IV fluids to prevent
dehydration. Antidiarrheal medication may or may not be appropriate as the diarrhea serves as
the portal of exit for the infection.
A nurse is observing as an assistive personnel (AP) performs hygiene and provides comfort
measures to a client with an infection. What action by the AP requires intervention by the
nurse?
a. Not using gloves while combing the client's hair
b. Rinsing the client's commode pan after use
c. Ordering an oscillating fan for the client
d. Wearing gloves when providing perianal care - Answer ANS: C
Fans in client care areas are discouraged because they can disperse airborne or droplet-borne
pathogens. The other actions are appropriate. If the client has a scalp infection or infestation,