Ignatavicius Chapter 21 TEST BANK
A client has been placed on Contact Precautions. The client's family is very afraid to visit for fear
of being "contaminated" by the client. What action by the nurse is BEST?
A. Explain to them that these precautions are mandated by law.
B. Show the family how to avoid spreading the disease.
C. Reassure the family that they will not get the infection.
D. Tell the family it is important that they visit the client. - ANS -B. Visitors may be apprehensive
about visiting a client in Transmission-Based Precautions. The nurse would reassure the visitors
that taking appropriate precautions will minimize their risks.
\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 - 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.
\A client is being admitted with suspected TB. What actions by the nurse are BEST? (SATA)
A. Admit the client to a negative-air-flow room.
B. Maintain a distance of 3 feet from the client at all times.
C. Obtain specialized respirations for caregiving
D. Other than wearing gloves, no special actions are needed.
E. Wash hands with chlorhexidine after providing care.
F. Assure client has a respirator for moving between departments. - ANS -A, C. A client with
suspected TB is admitted with AIRBOURNE Precautions, which includes a negative air-flow
room and a special N95 or PAPR masks to be worn when providing care.
\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 perineal care to assistive personnel
C. Place the client on NPO status until the diarrhea resolves.
D. Request a prescription for an antidiarrheal medication - ANS -A. Hospitalized patients who
have three or more stools a day for 2 or more days are suspected of having an infection with
CLOSTRIDIUM DIFFICILE. The nurse will inform the primary health care provider and request
stool cultures.
\A client is to receive a fecal microbiota transplantation tomorrow (FMT). What action by the
nurse is BEST?
A. Administer bowel cleansing as prescribed
B. Educate the client on immunosuppressive drugs.
C. Inform the client they will drink a thick liquid.
, D. Place a nasogastric tube to intermittent suction. - ANS -A. The usual route of delivering an
FMT is via a colonoscopy, so the client would have a bowel cleansing as prescribed for that
procedure.
\A client with an infection has a fever. What actions by the nurse help increase the client's
comfort? (SATA)
A. Administer antipyretics around the clock.
B. Change the client's gown and linens when damp.
C. Offer cool fluids to the client frequently
D. Place ice bags in the armpits and groin.
E. Provide a fan to help cool the client.
F. Sponging the client with tepid water. - ANS -B, C, F. Comfort measures appropriate for this
client include offering frequent cool drinks, and changing linens or the gown when damp.
\A hospitalized client is placed on Contact Precautions. The client needs to have a CT scan.
What action by the nurse is MOST appropriate?
A. Ensure the radiology department is aware of the Isolation Precautions.
B. Plan to travel with the client to ensure appropriate precautions are used.
C. No special precautions are needed when this client leaves the unit.
D. Notify the primary health care provider that the client cannot leave the room. - ANS -A.
Clients in isolation will leave their rooms only when necessary, such as for a CT scan that
cannot be done portably in the room. The nurse will ensure that the receiving department is
aware of the Isolation Precautions needed to care for the client.
\A nurse asks the supervisor why older adults are more prone to infection than other adults.
What reasons does the supervisor give? (SATA)
a. Age-related decrease in immune function
b. Decreased cough and gag reflexes
c. Diminished acidity of gastric secretions
d. Increased lymphocytes and antibodies
e. Thinning skin that is less protective
f. Higher rates of chronic illness - ANS -A, B, C, E, F. Older adults have several age-related
changes making them more susceptible to infection, including decreased immune function,
decreased cough and gag reflexes, decreased acidity of gastric contents, thinning skin, fewer
lymphocytes and antibodies, and higher rates of chronic illness.
\A nurse cares for several clients on an inpatient unit. Which infection control measures will the
nurse implement? (SATA)
A. Wear a gown when contact of clothing with body fluids is anticipated.
B. Teach clients and visitors respiratory hygiene techniques.
C. Obtain powered air purifying respirators for all staff members.
D. Do not use alcohol-based hand rub between client contacts.
E. Disinfect frequently touched surfaces in client-care areas. - ANS -A, B, E. Infection control
measures appropriate to all clients include hand hygiene with alcohol based rub or soap
between client contact, procedures for routine care, cleaning and disinfection of frequently
contaminated surfaces, and wearing PPE when contamination is anticipated.
\A nurse is caring for a client who has MRSA infection cultured from the urine. What action by
the nurse is MOST appropriate?
A client has been placed on Contact Precautions. The client's family is very afraid to visit for fear
of being "contaminated" by the client. What action by the nurse is BEST?
A. Explain to them that these precautions are mandated by law.
B. Show the family how to avoid spreading the disease.
C. Reassure the family that they will not get the infection.
D. Tell the family it is important that they visit the client. - ANS -B. Visitors may be apprehensive
about visiting a client in Transmission-Based Precautions. The nurse would reassure the visitors
that taking appropriate precautions will minimize their risks.
\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 - 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.
\A client is being admitted with suspected TB. What actions by the nurse are BEST? (SATA)
A. Admit the client to a negative-air-flow room.
B. Maintain a distance of 3 feet from the client at all times.
C. Obtain specialized respirations for caregiving
D. Other than wearing gloves, no special actions are needed.
E. Wash hands with chlorhexidine after providing care.
F. Assure client has a respirator for moving between departments. - ANS -A, C. A client with
suspected TB is admitted with AIRBOURNE Precautions, which includes a negative air-flow
room and a special N95 or PAPR masks to be worn when providing care.
\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 perineal care to assistive personnel
C. Place the client on NPO status until the diarrhea resolves.
D. Request a prescription for an antidiarrheal medication - ANS -A. Hospitalized patients who
have three or more stools a day for 2 or more days are suspected of having an infection with
CLOSTRIDIUM DIFFICILE. The nurse will inform the primary health care provider and request
stool cultures.
\A client is to receive a fecal microbiota transplantation tomorrow (FMT). What action by the
nurse is BEST?
A. Administer bowel cleansing as prescribed
B. Educate the client on immunosuppressive drugs.
C. Inform the client they will drink a thick liquid.
, D. Place a nasogastric tube to intermittent suction. - ANS -A. The usual route of delivering an
FMT is via a colonoscopy, so the client would have a bowel cleansing as prescribed for that
procedure.
\A client with an infection has a fever. What actions by the nurse help increase the client's
comfort? (SATA)
A. Administer antipyretics around the clock.
B. Change the client's gown and linens when damp.
C. Offer cool fluids to the client frequently
D. Place ice bags in the armpits and groin.
E. Provide a fan to help cool the client.
F. Sponging the client with tepid water. - ANS -B, C, F. Comfort measures appropriate for this
client include offering frequent cool drinks, and changing linens or the gown when damp.
\A hospitalized client is placed on Contact Precautions. The client needs to have a CT scan.
What action by the nurse is MOST appropriate?
A. Ensure the radiology department is aware of the Isolation Precautions.
B. Plan to travel with the client to ensure appropriate precautions are used.
C. No special precautions are needed when this client leaves the unit.
D. Notify the primary health care provider that the client cannot leave the room. - ANS -A.
Clients in isolation will leave their rooms only when necessary, such as for a CT scan that
cannot be done portably in the room. The nurse will ensure that the receiving department is
aware of the Isolation Precautions needed to care for the client.
\A nurse asks the supervisor why older adults are more prone to infection than other adults.
What reasons does the supervisor give? (SATA)
a. Age-related decrease in immune function
b. Decreased cough and gag reflexes
c. Diminished acidity of gastric secretions
d. Increased lymphocytes and antibodies
e. Thinning skin that is less protective
f. Higher rates of chronic illness - ANS -A, B, C, E, F. Older adults have several age-related
changes making them more susceptible to infection, including decreased immune function,
decreased cough and gag reflexes, decreased acidity of gastric contents, thinning skin, fewer
lymphocytes and antibodies, and higher rates of chronic illness.
\A nurse cares for several clients on an inpatient unit. Which infection control measures will the
nurse implement? (SATA)
A. Wear a gown when contact of clothing with body fluids is anticipated.
B. Teach clients and visitors respiratory hygiene techniques.
C. Obtain powered air purifying respirators for all staff members.
D. Do not use alcohol-based hand rub between client contacts.
E. Disinfect frequently touched surfaces in client-care areas. - ANS -A, B, E. Infection control
measures appropriate to all clients include hand hygiene with alcohol based rub or soap
between client contact, procedures for routine care, cleaning and disinfection of frequently
contaminated surfaces, and wearing PPE when contamination is anticipated.
\A nurse is caring for a client who has MRSA infection cultured from the urine. What action by
the nurse is MOST appropriate?
