Foundation Lab Final Exam 2

Chain of Infection

100

State the complete chain of Infection.

Infectious Agent > Reservoir > Portal of Exit > Mode of transmission> Portal of Entry > Susceptible Host

200

A nurse is educating a group of nursing students about the chain of infection. Which of the following scenarios best illustrates a portal of entry for an infectious agent?

A) A patient sneezes, releasing droplets into the air.

B) A mosquito bites a person, transmitting malaria.

C) A nurse washes her hands after patient care.

D) A patient with tuberculosis coughs into a tissue.

Correct Answer:

B) A mosquito bites a person, transmitting malaria.

Rationale:

• B) A mosquito bites a person, transmitting malaria. This scenario illustrates a portal of entry, as the mosquito bite provides a direct route for the malaria parasite to enter the bloodstream of the person, making them susceptible to infection.

300

A nurse is reviewing infection control practices with a group of nursing students. Which of the following scenarios best illustrates a portal of exit for an infectious agent?

A) A patient develops a rash after receiving a new medication.

B) A healthcare worker receives a hepatitis B vaccination.

C) A patient with influenza sneezes into a tissue.

D) A nurse applies a sterile dressing to a surgical wound.

Correct Answer:

C) A patient with influenza sneezes into a tissue.

Rationale:

• C) A patient with influenza sneezes into a tissue. This scenario illustrates a portal of exit, as the act of sneezing expels respiratory droplets containing the influenza virus from the patient's body into the environment, potentially spreading the infection to others.

400

A nurse is teaching a community health class about the transmission of infectious diseases. Which of the following scenarios best illustrates a mode of transmission for an infectious agent?

A) A patient develops a fever after surgery.

B) A healthcare worker receives a flu shot.

C) A person contracts norovirus after touching a contaminated doorknob and then touching their mouth.

D) A patient with a urinary tract infection experiences pain during urination.

Correct Answer:

C) A person contracts norovirus after touching a contaminated doorknob and then touching their mouth.

Rationale:

• C) A person contracts norovirus after touching a contaminated doorknob and then touching their mouth. This scenario illustrates a mode of transmission, specifically indirect contact transmission, where the infectious agent is transferred from a contaminated surface (the doorknob) to the person.

500

A nurse is explaining the chain of infection to a group of nursing students. Which of the following scenarios best illustrates a reservoir for an infectious agent?

A) A patient with an open wound receives antibiotic treatment.

B) A healthcare worker wears gloves while handling bodily fluids.

C) A contaminated water source leads to an outbreak of cholera in a community.

D) A person covers their mouth while coughing.

Correct Answer:

C) A contaminated water source leads to an outbreak of cholera in a community.

Rationale:

• C) A contaminated water source leads to an outbreak of cholera in a community. This scenario illustrates a reservoir, as the contaminated water serves as a habitat where the cholera bacteria can survive and multiply, facilitating the spread of the infection to humans.

600

A nurse is educating a group of nursing students about the chain of infection. Which of the following scenarios best illustrates an infectious agent?

A) A patient with tuberculosis is placed in an isolation room.

B) A nurse washes her hands before and after patient care.

C) A virus that causes the common cold is identified in a laboratory sample.

D) A person receives a tetanus booster shot after a puncture wound.

Correct Answer:

C) A virus that causes the common cold is identified in a laboratory sample.

Rationale:

• C) A virus that causes the common cold is identified in a laboratory sample. This scenario illustrates an infectious agent, as the virus is the microorganism responsible for causing the common cold.

Immunity

100

is a sophisticated immune response that develops over time and provides long-lasting protection against specific pathogens

Adaptive Immunity

200

is the body's first line of defense against pathogens. It is present from birth and provides immediate, general protection against a wide range of invaders. Unlike adaptive immunity, which is specific and develops over time, innate immunity does not require previous exposure to a pathogen to be effective.

Innate Immunity

300

 is a component of the adaptive immune system that is primarily mediated by B cells and the antibodies they produce. It is responsible for defending against extracellular pathogens, such as bacteria and viruses that are present in body fluids.

Humoral Immunity

400

 is a critical component of the adaptive immune system that involves the activation of T cells to defend against intracellular pathogens, such as viruses, some bacteria, and cancer cells.

Cellular Immunity

500

A nurse is educating a patient about the different types of immunity. Which of the following is an example of passive immunity?

A) A child receives a measles, mumps, and rubella (MMR) vaccine.

B) An adult develops immunity after recovering from a hepatitis A infection.

C) A newborn receives antibodies through breast milk.

D) An elderly person receives a booster shot for tetanus.

C) A newborn receives antibodies through breast milk.

Rationale:

• Option A: This is an example of active immunity, as the vaccine stimulates the body's immune system to produce its own antibodies.

600

Match each type of immunity with its correct description:

1. Innate Immunity
2. Adaptive Immunity
3. Humoral Immunity
4. Cellular Immunity

Descriptions:

A) This type of immunity involves the production of antibodies by B cells to neutralize pathogens.

B) This type of immunity provides a non-specific, immediate defense against pathogens and includes physical barriers and phagocytic cells.

C) This type of immunity involves T cells that directly attack infected or cancerous cells.

D) This type of immunity is specific and involves memory cells that provide long-lasting protection after exposure to a pathogen.

Answers:

1. Innate Immunity - B) This type of immunity provides a non-specific, immediate defense against pathogens and includes physical barriers and phagocytic cells.

2. Adaptive Immunity - D) This type of immunity is specific and involves memory cells that provide long-lasting protection after exposure to a pathogen.

3. Humoral Immunity - A) This type of immunity involves the production of antibodies by B cells to neutralize pathogens.

4. Cellular Immunity - C) This type of immunity involves T cells that directly attack infected or cancerous cells.

Infectious Agent

100

An infectious agent that causes disease is referred to as a ________________ ?

Pathogen

200

Match each type of medication with the type of infection it is primarily used to treat:

1. Antibacterial
2. Antiviral
3. Antifungal
4. Antiparasitic

Descriptions:

A) Used to treat infections caused by viruses, such as influenza or HIV.

B) Used to treat infections caused by bacteria, such as strep throat or urinary tract infections.

C) Used to treat infections caused by fungi, such as athlete's foot or candidiasis.

D) Used to treat infections caused by parasites, such as malaria or giardiasis.

Answers:

1. Antibacterial - B) Used to treat infections caused by bacteria, such as strep throat or urinary tract infections.

2. Antiviral - A) Used to treat infections caused by viruses, such as influenza or HIV.

3. Antifungal - C) Used to treat infections caused by fungi, such as athlete's foot or candidiasis.

4. Antiparasitic - D) Used to treat infections caused by parasites, such as malaria or giardiasis.

300

A patient is prescribed amoxicillin for a bacterial infection. Which of the following statements by the patient indicates a need for further teaching?

A) "I will take the entire course of antibiotics, even if I start feeling better."

B) "I can stop taking the medication once my symptoms have completely resolved."

C) "I should take the medication at evenly spaced intervals throughout the day."

D) "I will notify my healthcare provider if I develop a rash or difficulty breathing."

Correct Answer:

B) "I can stop taking the medication once my symptoms have completely resolved."

Rationale:

• Option B: This statement indicates a need for further teaching. Patients should not stop taking antibiotics just because symptoms have resolved; they should complete the prescribed course.

400

A patient with a newly diagnosed herpes simplex virus (HSV) infection is prescribed acyclovir. Which of the following instructions should the nurse include in the patient's teaching plan?

A) "Take the medication with food to enhance absorption."

B) "You can stop taking the medication once the lesions have healed."

C) "Increase your fluid intake while taking this medication."

D) "This medication will cure the herpes infection."

Correct Answer:

C) "Increase your fluid intake while taking this medication."

Rationale:

• Option C: Increasing fluid intake is important while taking acyclovir to help prevent kidney damage, as the drug can crystallize in the renal tubules.

500

A patient is prescribed itraconazole for the treatment of a fungal nail infection. Which of the following instructions should the nurse include in the patient's teaching plan?

A) "Take the medication on an empty stomach for better absorption."

B) "Avoid taking antacids within 2 hours of this medication."

C) "You may stop the medication once the nail appears normal."

D) "Expect to see immediate improvement in your nail condition."

Correct Answer:

B) "Avoid taking antacids within 2 hours of this medication."

Rationale:

• Option B: This statement is correct. Antacids can interfere with the absorption of itraconazole, so they should be avoided within 2 hours of taking the medication.

600

A patient is prescribed metronidazole for the treatment of giardiasis. Which of the following instructions should the nurse include in the patient's teaching plan?

A) "You can consume alcohol in moderation while taking this medication."

B) "Take the medication on an empty stomach to increase absorption."

C) "Report any metallic taste or darkening of urine to your healthcare provider immediately."

D) "Complete the full course of medication even if symptoms improve."

Correct Answer:

D) "Complete the full course of medication even if symptoms improve."

• Option D: This statement is correct. Completing the full course of medication is important to ensure the infection is fully treated and to prevent resistance.

Random

100

A nurse is assessing a patient who reports feeling lightheaded and dizzy upon standing. Which of the following conditions is most likely associated with these symptoms?

A) Orthostatic hypotension

B) Hypertension

C) Hyperglycemia

D) Deep vein thrombosis

Correct Answer:

A) Orthostatic hypotension

200

A patient is diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following precautions should the nurse implement to prevent the spread of this drug-resistant microorganism?

A) Standard precautions only

B) Airborne precautions

C) Droplet precautions

D) Contact precautions

Correct Answer:

D) Contact precautions

300

A nurse is preparing to exit the room of a patient on contact precautions. Which of the following is the correct sequence for doffing personal protective equipment (PPE)?

A) Gloves, gown, goggles or face shield, mask or respirator

B) Gown, gloves, mask or respirator, goggles or face shield

C) Mask or respirator, goggles or face shield, gown, gloves

D) Goggles or face shield, mask or respirator, gloves, gown

Correct Answer:

A) Gloves, gown, goggles or face shield, mask or respirator

400

A nurse is providing a bed bath to an immobile patient. Which of the following actions should the nurse take to maintain the patient's comfort and safety during the procedure?

A) Use hot water to ensure thorough cleaning.

B) Wash from the dirtiest to the cleanest areas.

C) Keep the patient covered with a bath blanket except for the area being washed.

D) Begin the bath by washing the patient's feet.

Correct Answer:

C) Keep the patient covered with a bath blanket except for the area being washed.

• Option C: Keeping the patient covered with a bath blanket except for the area being washed helps maintain the patient's dignity, warmth, and comfort.

500

A nurse is caring for a patient who has been on bed rest for an extended period. Which of the following complications should the nurse monitor for as a potential effect of immobility?

A) Increased cardiac output

B) Muscle hypertrophy

C) Pressure ulcers

D) Enhanced joint flexibility

Correct Answer:

C) Pressure ulcers

• Option C: Pressure ulcers, also known as bedsores, are a common complication of immobility due to prolonged pressure on the skin, especially over bony prominences.

600

A nurse is assessing a patient who has been immobile for several days. Which of the following respiratory complications should the nurse be most concerned about due to the patient's immobility?

A) Hyperventilation

B) Pulmonary embolism

C) Atelectasis

D) Increased lung expansion

Correct Answer:

C) Atelectasis

• Option C: Atelectasis, or the collapse of alveoli, is a common respiratory complication of immobility. It occurs due to decreased lung expansion and pooling of secretions, which can lead to impaired gas exchange and increased risk of pneumonia.

Fall Risk

100

A nurse is using a fall risk assessment tool to evaluate a newly admitted patient. Which of the following factors would most likely increase the patient's risk of falling?

A) The patient is 45 years old and ambulates independently.

B) The patient takes multiple medications, including a diuretic and a sedative.

C) The patient has a history of seasonal allergies.

D) The patient has a family member present at all times.

Correct Answer:

B) The patient takes multiple medications, including a diuretic and a sedative.

• Option B: Taking multiple medications, especially those like diuretics and sedatives, can increase fall risk. Diuretics may lead to frequent urination and potential dehydration, while sedatives can cause dizziness or drowsiness.

200

A nurse is using the Morse Fall Scale to assess a patient's risk of falling. Which of the following factors is included in the Morse Fall Scale assessment?

A) Patient's nutritional status

B) Patient's age

C) History of falling

D) Patient's family support

Correct Answer:   C) History of falling

The Morse Fall Scale is a tool used to assess a patient's risk of falling. It includes the following six factors:

1. History of falling: Whether the patient has fallen in the past, particularly within the last three months.
2. Secondary diagnosis: The presence of more than one medical diagnosis.
3. Ambulatory aid: The use of devices such as crutches, canes, or walkers.
4. IV/Heparin lock: Whether the patient has an intravenous line or heparin lock.
5. Gait/transferring: The patient's ability to walk and transfer, including any unsteadiness or difficulty.
6. Mental status: The patient's awareness of their own limitations and ability to follow instructions.

300

A nurse is using the Johns Hopkins Hospital (JHH) Fall Risk Assessment Tool to evaluate a patient's risk of falling. Which of the following factors is assessed in this tool?

A) Patient's dietary habits

B) Patient's age

C) Patient's fear of falling

D) Patient's use of assistive devices

Correct Answer: D) Patient's use of assistive devices

The Johns Hopkins Hospital (JHH) Fall Risk Assessment Tool is a comprehensive tool used to evaluate a patient's risk of falling. It includes several factors, such as:

1. Age: Older age is associated with a higher risk of falls.
2. Fall history: Previous falls increase the risk of future falls.
3. Elimination: Issues such as incontinence or frequent urination can contribute to fall risk.
4. Medications: Certain medications, especially those affecting the central nervous system, can increase fall risk.
5. Patient care equipment: The use of equipment like IV lines or catheters can increase fall risk.
6. Mobility: The patient's ability to move independently or with assistance.
7. Cognition: The patient's mental status and ability to follow instructions.
8. Use of assistive devices: The use of canes, walkers, or other devices is assessed as it can impact mobility and stability.

400

A nurse is using the International Classification for Nursing Practice (ICNP) to document a patient's care plan. The patient has been identified as having a high risk for falls. Which ICNP nursing diagnosis is most appropriate for this patient?

A) Impaired Physical Mobility

B) Risk for Falls

C) Activity Intolerance

D) Impaired Walking

Correct Answer:

B) Risk for Falls

• Option B: "Risk for Falls" is the most appropriate ICNP nursing diagnosis for a patient identified as having a high risk for falls. It directly addresses the potential for falls and is used to guide interventions aimed at preventing falls.

500

A nurse is developing a care plan for a hospitalized patient who is at high risk for falls. Which of the following interventions should be included to help prevent falls?

A) Keep the bed in the highest position to prevent the patient from getting out of bed unassisted.

B) Ensure that the call light is within the patient's reach at all times.

C) Encourage the patient to wear socks when ambulating in the room.

D) Place all personal items on the far side of the room to encourage movement.

Correct Answer:  B) Ensure that the call light is within the patient's reach at all times.

• Option B: Ensuring that the call light is within the patient's reach allows the patient to easily call for assistance when needed, which is a key intervention in preventing falls.

600

A nurse is caring for an elderly patient who has been identified as a high fall risk. Which of the following interventions should the nurse implement to reduce the risk of falls? (Select all that apply.)

A) Place a fall risk identification bracelet on the patient.

B) Keep the patient's bed in the lowest position with wheels locked.

C) Encourage the patient to use the bathroom without assistance to promote independence.

D) Ensure adequate lighting in the patient's room and bathroom.

E) Remove clutter and obstacles from the patient's room and pathways.

Correct Answers:

A) Place a fall risk identification bracelet on the patient.

B) Keep the patient's bed in the lowest position with wheels locked.

D) Ensure adequate lighting in the patient's room and bathroom.

E) Remove clutter and obstacles from the patient's room and pathways.