Block 3 Assessment 1: Module 3-4
a. stage 3 pressure injury e. open burn area 1. primary intention: when wound has little tissue lost 2. secondary intention: wound involving loss of tissue
A nurse educator is reviewing the wound healing process with a group of nurses. The nurse educator should include in the information which of the following alterations for the wound healing by secondary intention? (SATA) a. stage 3 pressure injury b. sutured surgical incision c. casted bone fracture d. laceration sealed with adhesive e. open burn area
b. nurse moistens cotton ball with sterile normal saline and places it on the sterile field c. procedure is delayed 1 hr bc the provider receives an emergency call d. nurse turns to speak to someone who enters the door behind the nurse
A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (SATA) a. provider drops a sterile instrument onto the near side of the sterile field b. nurse moistens cotton ball with sterile normal saline and places it on the sterile field c. procedure is delayed 1 hr bc the provider receives an emergency call d. nurse turns to speak to someone who enters the door behind the nurse e. client's hand brushes against the outer edge of the sterile field
d. flap farthest from the body Closest = last to unfold
A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? a. flap closest to the body b. right side flap c. left side flap d. flap farthest from the body
D) Cleaning the least-soiled areas prior to cleaning the most-soiled areas.
A nurse is assisting a patient with personal hygiene care. Which of the following actions by the nurse will reduce the risk of infection? A) Massaging reddened areas of the patient's skin B) Washing eyes from the outer canthus to the inner C) Washing the patient from the shoulder down to the fingertips with smooth, short strokes D) Cleaning the least-soiled areas prior to cleaning the most-soiled areas
d. tuberculosis
A nurse is caring for a client who has had a cough for 3 weeks and is beginning to cough up blood. The client has manifestations of which of the following conditions? a. allergic reaction b. ringworm c. systemic lupus erythematosus d. tuberculosis
a. planning and evaluating control b. determining public health priorities c. ensuring proper medical treatment e. monitoring for common-source outbreaks Endemic disease is already prevalent within the population, so reporting is unnecessary
A nurse is caring for a client who has severe acute respiratory syndrome (SARS). The nurse knows that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (SATA) a. planning and evaluating control b. determining public health priorities c. ensuring proper medical treatment d. identify endemic diseases e. monitoring for common-source outbreaks
b. chronic illness c. low hemoglobin d. malnutrition The client is not at either extreme of the age spectrum. Diabetes Mellitus is a chronic illness. Hgb (Hemoglobin) normally is 13.8 - 17.2 g/dL Normal BMI is 18.5 - 24.9 No indication of breaches in aseptic technique during wound care.
A nurse is caring for a client who is 2 days postoperative following an appendectomy and has type 1 diabetes mellitus. Their Hbg is 12 g/dL and BMI is 17.1. The incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the client has which of the following risk factors for impaired wound healing? (SATA) a. extremes in age b. chronic illness c. low hemoglobin d. malnutrition e. poor wound care
a. keep the head of the bed elevated 30 degrees d. have the client sit on a gel cushion when in a chair Repositioning the client at least every 2 hr to prevent skin breakdown. 3 hr is not enough
A nurse is caring for a client who is at risk for developing pressure injury. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin (SATA) a. keep the head of the bed elevated 30 degrees b. massage the client's bony prominences frequently c. apply cornstarch liberally to the skin after bathing d. have the client sit on a gel cushion when in a chair e. reposition the client at least every 3 hour while in bed.
A. a cotton ball dampened with sterile normal saline is placed on the field. D. the nurse turns to address the patient's question concerning the procedure. E. the procedure is postponed for 30 minutes to accommodate the patient.
A nurse preparing a sterile field knows that the field has been contaminated when (Select all that apply.) A. a cotton ball dampened with sterile normal saline is placed on the field. B. a contaminated instrument touches the outer edge of the sterile field. C. a sterile instrument is dropped onto the nearside of the sterile field. D. the nurse turns to address the patient's question concerning the procedure. E. the procedure is postponed for 30 minutes to accommodate the patient. F. a liquid is poured into a sterile container from a distance of 4 inches.
D. control the introduction of micro-organisms at the catheter site
A nurse preparing to flush and change the dressing on a patient's central venous catheter should understand that the primary purpose for performing this intervention using surgical asepsis is to A. promote the catheters patency. B. assess the skin's integrity around the catheter site. C. provide a clean, dry environment for the catheter. D. control the introduction of micro-organisms at the catheter site
c. If dressing becomes saturated with sanguineous drainage, reinforce dressing and notify surgeon
Post Operative dressing changes: A general 'rule of thumb' for 'fresh' post surgical dressings is: If dressing becomes saturated... a. ,take dressing completely off and replace with sterile dressing b. with serous drainage, cover with a plastic barrier to prevent soiling bed linens c. with sanguineous drainage, reinforce dressing and notify surgeon d. , that's normal. Document in the patient's record.
A. Gown C. Hair cover D. Mask E. Shoe covers
Prior to entering the surgical-scrub area which of the following personal protective equipment (PPE) items to do the team members don? (Select all that apply.) A. Gown B. Protective eyewear C. Hair cover D. Mask E. Shoe covers
a. hematocrit 58%
Signs & symptoms of bacterial infection include all of the following EXCEPT: a. hematocrit 58% b. WBC 16,000 c. neutrophils 78% d. purulent drainage form incision
d. polycythemia leukocytosis: increase in WBC polycythemia: increase in RBC febrile: showing the symptoms of a fever.
Signs & symptoms of infection include all of the following EXCEPT: a. leukocytosis b. purulent drainage c. febrile d. polycythemia
d. coolness
Signs & symptoms of infection include all of the following EXCEPT: a. redness (erythema) b. swelling (edema) c. heat d. coolness
c. Previous problem-solving strategies The nurse can use previous problem-solving strategies to assess an adult's developmental stage as it relates to intellectual functioning. The other choices are related to physiological attributes.
To assess an adult's developmental stage, which of the following should the nurse consider? a. Height and weight b. Blood pressure c. Previous problem-solving strategies d. Pulse rate
a. Drying provides the full antiseptic effect
To decontaminate your hands with an alcohol-based gel, you rub them together until all of the gel has evaporated and your hands are dry. The primary reason you do this is that a. Drying provides the full antiseptic effect b. Residual alcohol can easily stain clothing c. Excess gel could transfer to the patient d. Slippery gel can make you drop supplies
negative; N59 respirator
To prevent airborne transmission, nurses should offer a private room with (negative/positive) pressure airflow, along with wearing what kind of PPE?
gloves and gown
To prevent contact transmission, nurses should offer a private room and wear what kind of PPE?
mask or respirator
To prevent droplet transmission, nurses should offer a private room and wear what kind of PPE?
positive; must
To protect environment from allogeneic hematopoietic stem cell transplant, nurses should offer a private room with (negative/positive) airflow and clients (must/mustn't) wear a mask when out of the room.
protective vascular reaction that delivers fluid, blood products, and nutrients to an area of injury fights and rid pathogens or dead tissues (necrotic) and helps in repair of body cells and tissue
Describe inflammation and its purpose
after they find a reservoir, must exit : blood, skin, mucous membranes, respiratory tract, GU tract, GI tract, pregnancy.
Describe port of exit from reservoir, and give examples
The conditions in which people are born, grow, live, work, and age
Describe social determinants of health
1. non-prescriptions: abstinence, barrier methods, spermicide, rhythm method 2. hormonal contraception, IUD, diaphragm, cervical cap, sterilization 3. abortion: provide environment for client to discuss openly
Describe the 3 ways of contraception
Stage 1: non-blanchable redness Stage 2: partial-thickness loss with exposed dermis Stage 3: full-thickness loss, w/o undermining, see fat Stage 4: 3+ undermining, see tendon, muscle, bone Unstageable: full-thickness skin or tissue loss with unknown depth
Describe the 5 stages of pressure ulcer wounds
development: occurs across the lifespan from infancy to older adulthood identity: how a person thinks about themselves sexually orientation: pattern of a person's attraction
Describe the differences between sexual development, identity, and orientation
1. primary intention: when wound has little tissue lost - surgical incision (stitches, staples, skin glue, or steri-strips) - skin edges are approximated or closed - risk of infection low 2. secondary intention: wound involving loss of tissue - burns, pressure ulcers, or severe laceration - wound is left open until becomes filled by scar tissue - higher chance of infection due to time it take wound to heal - edges can't be brought together; takes longer to heal 3. tertiary intention: need to delay closing a wound - poor circulation in the wound area or infection - ex: abdominal wound that is kept open in order to allow drainage, and then later closed
Describe the primary, secondary, and tertiary intention in wound healing
Usually loosely attached to the skin surface, and almost completely removed by thoroughly washing with soap or detergent and water
Describe transient organisms
formation of granulation tissue (not as strong of tissue collagen) assumes form of scar tissue
Describe what happens in tissue repair
a. measles g. varicella f. TB (tuberculosis)
Examples of airborne bacteria/diseases are: a. measles b. diphtheria c. pneumonia d. MRSA e. c diff f. TB (tuberculosis) g. varicella h. scarlet fever i. mumps j. pertussis k. herpes l. major wounds
d. MRSA e. c diff k. herpes l. major wounds
Examples of contact bacteria/diseases are: a. measles b. diphtheria c. pneumonia d. MRSA e. c diff f. TB (tuberculosis) g. varicella h. scarlet fever i. mumps j. pertussis k. herpes l. major wounds
b. diphtheria c. pneumonia h. scarlet fever i. mumps j. pertussis
Examples of droplet bacteria/diseases are: a. measles b. diphtheria c. pneumonia d. MRSA e. c diff f. TB (tuberculosis) g. varicella h. scarlet fever i. mumps j. pertussis k. herpes l. major wounds
False
For optimal health, an individual should bathe daily (T/F)
b. secondary intention
Generally speaking, which type of wound/incision healing would have the biggest scar? a. primary intention b. secondary intention
rights of passage pregnancy-childbirth grief and loss death and dying
Give examples of cultural life transitions
bacteria, viruses, fungi, protozoa
Give examples of microorganisms
bacteria; curable
Gonorrhea, chlamydia, and syphilis are STI caused by ____ and (are/are not) curable sexually-transmitted diseases
a. promote independence
In caring for clients of all ages, especially in terms of hygiene care, a general rule of thumb is: a. promote independence b. facilitate dependence
A. With your hands clasped together in front of your body above waist level
Well waiting for a sterile procedure to begin, how do you position your hands and arms? A. With your hands clasped together in front of your body above waist level B. At the sides of your body with your hands pointing downward C. Folded across your chest with your hands on your shoulders D. With your hands clasped together in the back of your body at waist level
1.) sensory perception 2.) moisture 3.) activity 4.) mobility 5.) nutrition 6.) friction/shear
What are the 6 subscales of the Braden Scale? (SMAMNF/S)
Very High Risk: Total Score 9 or less. High Risk: Total Score 10-12. Moderate Risk: Total Score 13-14.
What are the Braden Scale assessment score scale?
Heat: improves blood flow to injured part, but should not be applied for more than 1 hr Cold: initially diminishes swelling and pain
What does heat and cold do for pain?
phagocytosis destruction and absorption of bacteria
What happens to the bacteria within inflammation?
assess risk of skin breakdown
What is the purpose of the Braden Scale?
the wound should be covered with a sterile dressing moistened with warm saline call the doctor
What should a nurse do when encountering evisceration?
a. negative sanctions for staff members for non-compliance negative sanctions: embarrassment, shame, ridicule, sarcasm, criticism, disapproval, social discrimination, and exclusion
What's NOT the best way to reduce infections on an acute care unit? a. negative sanctions for staff members for non-compliance b. educate staff, patients, and families regarding infection control measures c. prevent wound infections by practicing and promoting surgical asepsis d. appropriate hand washing with soap and water
d. prevents/delays wound healing
What's your (first) major concern when a wound (surgical or otherwise) is infected? a. prolonged hospital stay b. medicare non-payment for sentinel event c. patient might get a fever d. prevents/delays wound healing e. possibility of systemic infection
elevate head of bed 30 or less and change position every 2 hours if possible
When alleviating pressure ulcers, how would you position the patient?
b. Explain the procedure to the client. Explaining the procedure educates the client regarding the dressing change and involves him in his care, thereby allowing the client some control in decreasing anxiety. Telling the client to close his eyes and turning on the television are distractions that do not usually decrease a client's anxiety. If the family is a support system, asking support systems to leave the room can actually increase a client's anxiety.
While gathering supplies to perform wound care, the nurse notes the client appears anxious. Which nursing action is most appropriate? a. Instruct client to close his eyes. b. Explain the procedure to the client. c. Turn on the television. d. Ask family to leave the room.
A) raise the room temperature
While performing a complete bed bath for a patient, the nurse should: A) raise the room temperature B) completely remove linens C) add soap to the water in the basin before beginning the bath D) Complete the bathing for one side of the body at a time
c. moist
Would heal best if they are: a. dry b. wet c. moist
c. A face shield
You are about to irrigate a patient's open wound. Besides gloves, which other item of personal protective equipment (PPE) must you wear? a. A sterile gown b. Goggles c. A face shield d. An N95 respirator
c (furthest) a (side) b (closest)
You are about to open a sterile pack. Placed the following steps in the proper sequence for opening the sterile pack. A. The side flaps B. The flat closest to your body C. The flat furthest from your body
b. Protect your eyes
You are caring for a patient diagnosed with mycoplasmal pneumonia. Droplet precautions have been instituted, so you must a. Wear a respirator b. Protect your eyes c. Use an air filter d. Wear shoe covers
b. place on protective isolation Neutropenic precautions: WBC is 2,200 mm3 (too low); normally it's 4,000-10,000 mm3
You are on an acute care unit, and you are the nurse caring for a client with the following lab values: RBC 5.4 million WBC 2200 Hgb 14 Hct 48% What is your priority action for this patient? a. place on respiratory isolation b. place on protective isolation c. have visitors wear N95 mask when they are present d. these are normal values. No precautions are necessary, beyond "standard precautions"
b. Continue for at least 15 seconds
You are washing your hands with a nonantimicrobial soap and water prior to repositioning a patient in bed. During the hand washing procedure, it is important to a. Make sure that the water is hot b. Continue for at least 15 seconds c. Use a liquid soap preparation d. Remove rings and watches first
b. clients have the right to self-determination. They may forgo bathing.
You are working on an acute care unit, and have an elderly client. In terms of hygiene, Which of the following is important to remember In caring for this client? a. all clients on an acute care unit should be bathed at least daily b. clients have the right to self-determination. They may forgo bathing. c. daily bathing is not required to maintain health d. elderly clients have very supple, tough skin; as well they have very oily skin. Therefore, they should be educated to bathe daily
neutrophils and monocytes
_______ and _______ are specialized WBCs that ingest and destroy microorganisms and debris
does
port of entry (does/does not) have the same entry as the exit of the body
1. assessing patients skin at least 1x per day 2. ensure skin is clean and dry 3. choose skin care products based on patient need and hospital stock 4. moisture barrier products can be applied to exposed areas for patients with draining wounds, incontinent, or excessive sweating
what are some ways you can manage skincare and incontinences management for pressure ulcers? 1. assessing patients skin at least 1x per day 2. ensure skin is clean and dry 3. choose skin care products based on patient need and hospital stock 4. moisture barrier products can be applied to exposed areas for patients with draining wounds, incontinent, or excessive sweating 5. providing ROM care 6. give a foley catheter in case of urination
awareness, skill, knowledge, encounters, desire
Describe cultural ASKED
a. fever b. malaise e. increase in pulse and respiratory rate Malaise: general feeling of discomfort, illness, or uneasiness whose exact cause is difficult to identify. Edema and pain/tenderness are localized
A charge nurse is reviewing with a newly hired nurse the difference in manifestations of a localized versus a systemic infection. Which of the following are manifestations of a systemic infection? (SATA) a. fever b. malaise c. edema d. pain or tenderness e. increase in pulse and respiratory rate
b. Registered dietician Assessment and a plan for the client to optimize the diet are essential. Adequate calories, protein, vitamins, and minerals promote wound healing. The nurse is the coordinator of care, and collaborating with the dietician would result in planning the best meals for the client. The respiratory therapist can be consulted when a client has issues with the respiratory system. Case management can be consulted when the client has a discharge need. A chaplain can be consulted when the client has a spiritual need.
A client has a nursing diagnosis of Impaired Skin Integrity. Which member of the health care team is priority for the nurse to consult with? a. Respiratory therapist b. Registered dietician c. Chaplain d. Case manager
No Indwelling urinary catheter are only for those with urinary problems and need a doctor's order. Instead, you must clean up the moisture and change the bed often.
A client is grossly incontinent of urine, and the nurse is concerned about skin breakdown due to the constant moisture on the client's skin. The nurse decides to insert an indwelling urinary catheter. Is this a proper reason to insert a catheter? (Y/N)
a. cover the area with saline-soaked sterile dressings d. position the client supine with the hips and knees bent Binder can help prevent, not treat, evisceration. Don't handle/apply pressure to any exposed organs/tissues. Position minimizes pressure on abdominal area. Keep patient NPO
A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in their surgical incision. The nurse checks the surgical wound and finds it separated with viscera producing. Which of the following actions should the nurse take? (SATA) a. cover the area with saline-soaked sterile dressings b. apply an abdominal binder snugly around the abdomen c. use sterile gauze to apply gentler pressure to exposed tissues d. position the client supine with the hips and knees bent e. offer the client a warm beverage (herbal tea)
False sweat glands work less Skin thin & less resilient
A daily bath will keep an elderly person's skin soft and moist (T/F)
B. the inner edge of the cuff will lie against the skin and thus will not be sterile.
A nurse donning sterile gloves knows that the proper technique for gloving the dominant hand prevents contact between the contaminated hand and the noncontaminated glove because A. Slipping the fingers beneath the cuff maintains the gloves' sterility. B. the inner edge of the cuff will lie against the skin and thus will not be sterile. C. gloving the dominant hand first allows for better control over the process. D. the hand has been surgically scrubbed and is considered noncontaminated.
c. Request assistance from coworkers and utilize a transfer sliding board to reposition the client. When repositioning the client, obtain assistance and utilize a transfer sliding board under the client's body to prevent dragging the client on bed sheets and placing the client at high risk for shearing and friction injuries. The client should be placed in a 30-degree lateral position, not supine position. The head of the bed should be elevated less than 30 degrees to prevent pressure ulcer development from shearing forces.
A nurse is caring for a client who is immobile and at risk for skin breakdown, so includes a regular turning schedule in this client's plan of care. Which of the following nursing interventions is most appropriate when repositioning this client? a. Request assistance from coworkers and use a draw sheet to lift and reposition the client. b. Before repositioning, place the client in a 30-degree supine position. c. Request assistance from coworkers and utilize a transfer sliding board to reposition the client. d. Elevate the head of the bed 45 degrees before repositioning the client.
d. illness Incubation: pathogen first enters Prodomal: nonspecific manifestations Illness: specific manifestations Convalescence: manifestation fades
A nurse is caring for a client who reports a sever sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection. a. prodromal b. incubation c. convalescence d. illness
A) Moisture from excessive diaphoresis can cause skin breakdown
A nurse is caring for a patient who is on long-term bedrest and requires linen changes due to excessive diaphoresis. What is the priority rationale for frequent linen changes? A) Moisture from excessive diaphoresis can cause skin breakdown B) Moisture on the sheets can cause discomfort for the patient C) It provides an opportunity to frequently evaluate the patient's skin on his backside D) It provides an opportunity to turn patient from side to side to facilitate clearing potential fluid from the lungs
B) "Oral care is still important even though you are not eating."
A nurse is caring for an adult patient who is NPO. The patient is refusing oral care. What is an appropriate response by the nurse? A) "Since you are not eating, we can wait and do it at bedtime." B) "Oral care is still important even though you are not eating." C) "I'll give you a sip of water to swish around and then you can spit it out." D) "We will wait until your family gets here to help."
C) "I'll swab the patient's mouth with diluted hydrogen peroxide."
A nurse is caring for an unconscious patient. Which of the following statements by the nurse indicates an understanding of providing good oral hygiene for the patient? A) "I'll swab the patient's mouth with lemon-glycerin swabs." B) "I'll swab the patient's mouth with mouthwash." C) "I'll swab the patient's mouth with diluted hydrogen peroxide." D) "I'll swab the patient's lips with a very small amount of mineral oil."
a. increase in incisional pain b. fever and chills c. reddened wound edges
A nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? (SATA) a. increase in incisional pain b. fever and chills c. reddened wound edges d. increase in serosanguineous drainage e. decrease in thirst
b. wear a mask when providing care within 3 ft of the client c. place a surgical mask on the client if transportation is another department is unavoidable e. wear a gown when performing care that might result in contamination from secretions Pertussis, also known as whooping cough, is a highly contagious respiratory disease; transmitted mainly by airborne droplets Wear non-sterile gloves and gown when handling body fluids
A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse include? (SATA) a. place the client in a room that has negative air pressure of at least six exchanges per hour b. wear a mask when providing care within 3 ft of the client c. place a surgical mask on the client if transportation is another department is unavoidable d. use sterile gloves when handling soiled linens e. wear a gown when performing care that might result in contamination from secretions
1. Gather all necessary supplies 2. place a rubber mat on the tub floor 3. assist the patient into the bathroom 4. Instruct the patient on using safety bars when getting in and out of the tub 5. Instruct the patient to remain in the tub for no longer than 20 min
A nurse is preparing to assist a patient with a tub bath. Identify the sequence of steps the nurse should take (put them in order) - Instruct the patient to remain in the tub for no longer than 20 minutes - Place a rubber mat on the tub floor - Gather all necessary supplies - Instruct the patient on using safety bars when getting in and out of the tub - Assist the patient into the bathroom
b. wash hands with soap and water for at least 15 seconds d. use a clean paper towel to turn off hand faucets APs should apply alcohol rubs to dry hands and wet hands before applying soap for handwashing. APs should use warm water to minimize removal of protective skin oils. APs should dry their hands with a clean paper towel to prevent chapped skin.
A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing handwashing? (SATA) a. apply 3-5 mL of liquid soap to dry hands b. wash hands with soap and water for at least 15 seconds c. rinse the hands with hot water d. use a clean paper towel to turn off hand faucets e. allow the hands to air dry after washing
c. inner wrapping of an item on the sterile field d. irrigation syringe on the sterile field e. one gloved hand with the other gloved hand The bottle is sterile on the inside, but non-sterile on the outside. The 1-inch border of the sterile field is nonsterile
A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique? (SATA) a. bottle containing a sterile solution b. edge of sterile drape at the base of the field c. inner wrapping of an item on the sterile field d. irrigation syringe on the sterile field e. one gloved hand with the other gloved hand
C) The AP reuses the patient's blanket and spread
A nurse observes an assistive personnel (AP) make a client's bed while the client is out of the room. Which of the following actions by the AP is appropriate for this task? A) The AP records the task when it is completed B) The AP wears sterile gloves while making the bed C) The AP reuses the patient's blanket and spread D) The AP makes a mitered corner with the blanket and spread
a. Stage I Stage I intact pressure ulcers that resolve slowly without epidermal loss over 7 to 14 days do not require a dressing. This allows visual inspection and monitoring. A transparent dressing could be used to protect the client from shear but cannot be used in the presence of excessive moisture. A composite film, hydrocolloid, or hydrogel can be utilized on a clean stage II. A hydrocolloid, hydrogel covered with foam, calcium alginate, gauze, and growth factors can be utilized with a clean stage III. Hydrogel, calcium alginate, gauze, and growth factors can be utilized with a clean stage IV. An unstageable wound cover with eschar should utilize a dressing of adherent film or gauze with an ordered solution of anzymes. In rare cases when eschar is dry and intact, no dressing is used, but this is an unstaged ulcer.
A nurse working on a medical-surgical unit is assigned to care for several clients who have wounds. The nurse understands which of the following wounds does not require a dressing? a. Stage I b. Stage II c. Stage III d. Stage IV
d. Acquired the infection while hospitalized
A patient has a healthcare-associated infection. This term means that the patient a. Became infected due to compromised immunity b. Was infected during a therapeutic procedure c. Inhaled pathogens in a healthcare setting d. Acquired the infection while hospitalized
b. secondary intention
A surgical wound dehisces, and the surgeon decides to not re-suture, but to let the wound heal by: a. primary intention b. secondary intention c. tertiary intention
soft, yellow or white tissue that must be removed before wound is able to heal
Define slough
Complete elimination or destruction of all microorganisms including spores - adhere to policies and procedures in health care
Define sterilization
symptomatic: presence of signs and symptoms of an infection asymptomatic: no presense of signs and symptoms
Define symptomatic and asymptomatic
b. Wash your hands with soap/water
After assisting a newly admitted patient in removing his shoes and outerwear, you notice what appears to be soil on your hands. You a. Cleanse your hands with an alcohol-based gel. b. Wash your hands with soap/water c. Brush off the soil against a cloth surface d. Use a wet paper towel to remove the soil
a. The gloves
After completing a procedure that required donning PPE consisting of a gown, an N95 respirator, a face shield, and gloves, which of the following should the nurse remove first when removing PPE separately? a. The gloves b. The gown c. The face shield d. The N95 respirator
Dehiscence: partial or total separation of wound layers Evisceration: total separation of wound layers with protrusion of visceral organs through wound opening
Describe Dehiscence vs Evisceration
passed in feces and spread to food, surfaces and objects when people who are infected don't wash their hands thoroughly can persist in a room for weeks or months
Clostridium difficile (c. diff) concerns.
d. Infectious diarrhea
Contact precautions would be mandated for a hospitalized adult patient diagnosed with a. Hepatitis B. b. Measles c. Meningitis d. Infectious diarrhea
Permission to discuss sexuality issues Limited Information related to sexual health problems being experienced Specific Suggestions—only when the nurse is clear about the problem Intensive Therapy—referral to professional with advanced training if necessary
Describe PLISSIT when assessing sexuality
personal protective equipment gowns, masks, eyewear, gloves
Define PPE and list the different types
absence of pathogenic microorganisms (medical and surgical)
Define asepsis
remove soil from objects and surfaces
Define cleaning
presence and growth of microorganisms within a host but without tissue invasion or damage
Define colonization
process of becoming culturally sensitive to meet the health care need of today's client
Define cultural competence
cultural ignorance or blindness of others causes people to use their own values and lifestyle as guide in dealing with patients and interpreting their behavior
Define cultural imposition
removal of nonviable, necrotic tissue to rid the wound of source of infection
Define debridement
eliminates many/all microorganisms from inanimate objects (exception: bacterial spores)
Define disinfection
part of patient's flora becomes altered and overgrowth results
Define endogenous
inability of an adult male to achieve an erection; impotence
Define erectile dysfunction
black or brown necrotic tissue that must be removed before healing proceeds
Define eschar
Belief in the superiority of one's nation or ethnic group. causes bias and prejudice
Define ethnocentrism
microorganisms found outside individual
Define exogenous
fluid, such as pus, that leaks out of an infected wound (drainage)
Define exudate
red and moist tissue that normally forms during the healing of a wound
Define granulation tissue
A particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage
Define health disparity
a solid swelling of clotted blood within the tissues.
Define hematoma
bleeding from a wound site
Define hemorrhage
type of hospital-acquired infections (HAI) caused by invasive diagnostic or therapeutic procedure
Define iatrogenic
microorganisms invade wound tissue; inhibit wound healing
Define infection
ingesting bacteria
Define phagocytosis
contains WBCs and bacteria (thick and yellow)
Define purulent/puss
place where microorganisms survive, multiply, and await transfer to susceptible host
Define reservoir
organisms on skin
Define resident organisms
Containing RBCs; Bright Red is Fresh Bleeding; Dark Red is darker older bleeding
Define sanguineous
Pale, red, watery: mixture of clear and red fluid
Define serosanguineous
clear, watery plasma drainage
Define serous
Shear: sliding movement of skin and subcutaneous tissue while underlying muscle and bone are stationary Friction: force of two surfaces moving across one another
Define shear and friction
b. "I will give you the prescribed oral analgesic 30 minutes before the procedure, to make sure that the procedure is not too uncomfortable for you."
Dressing Changes: You are the nurse caring for a post-operative patient, and are about to change an abdominal dressing. The client appears anxious, and relates that previous dressing changes have been "very uncomfortable." Nurse---Which is your best response? a. "I will assess your pain level on a scale of 0-10 after the dressing change, and if warranted, I will provide you with the prescribed pain medication." b. "I will give you the prescribed oral analgesic 30 minutes before the procedure, to make sure that the procedure is not too uncomfortable for you." c. "It's a dressing change, and it should not be painful at all. Those other nurses probably didn't know how to do the procedure correctly." d. "Since the procedure is painful for you, I will notify the provider."
offer pain meds 30-60 min prior to dressing change
Dressing changes can add additional pain and anxiety. What can you do to alleviate that?
b. Failing eyesight, especially close vision Failing eyesight, especially close vision, is one of the first signs of aging in middle life (ages 46 to 64). More frequent aches and pains begin in the early late years (ages 65 to 79). Increase in loss of muscle tone occurs in later years (ages 80 and older). Accepting limitations while developing assets is socialization development that occurs in adulthood (ages 31 to 45).
During assessment of a 48 year old client, the nurse recognizes which of the following as one of the first physical signs of aging? a. Experiencing more frequent aches and pains b. Failing eyesight, especially close vision c. Increasing loss of muscle tone d. Accepting limitations while developing assets
D. encourage water and soap to flow away from the clean hands
During surgical handwashing the hands are kept above the elbows to A. keep them from coming into contact with a contaminated object. B. facilitate the application of sufficient friction to the hands. C. provide good visualization of the hands as they are scrubbed. D. encourage water and soap to flow away from the clean hands.
virus; uncurable
HSV, HPV, and HIV are STI caused by ____ and (are/are not) curable sexually-transmitted diseases
Higher: increase in acute infection - leukocytosis Lower: certain viral or overwhelming infection - leukopenia - need protective isolation
Higher WBC indicates what? Lower?
(1) skin care and management of incontinence; (2) mechanical loading and support devices, which include proper positioning and the use of therapeutic surfaces; and (3) education.
List 3 preventions of pressure ulcers
1. serous: clear plasma-like fluid 2. serosanguineous: a mixture of clear and red 3. sanguineous: contains RBC 4. purulent/puss: contains WBC and bacteria (thick and yellow)
List 4 types of wound drainage
1. direct contact 2. indirect (objects) 3. droplet 4. airborne 5. vehicles 6. vector (insects)
List 6 ways a disease can spread (DIDAVV)
1. airborne (measles, varicella, TB) - transport by air - private room with negative pressure airflow - N95 respirator 2. droplet (diphtheria, pneumonia, scarlet fever, pertussis, mumps, etc) - drops of moisture expelled - private room - mask or respiratory required 3.contact (MRSA, C diff, herpes, major wounds, etc) - physical touch - private room - gloves and gown 4. protective equipment (allogeneic hematopoietic stem cell transplant) - private room with positive airflow - mask worn by patient when out of room
List out insolation precautions from OSHA regulations and CDC guidelines and what can be prevented
multiple illness or critical illness older adults poorly nourished underlying medical conditions - diseases of immune system or other chronic diseases - burns - intravenous catheters or indwelling urinary catheters - stress
List some risk factors for infection
1. incubation: entrance of pathogen and first symptom 2. prodromal: onset of nonspecific signs/symptoms to more specific type of infection 3. illness: interval when patient has signs and symptoms to the type of infection 4. convalescence: interval when acute signs/symptoms disappear; recovery
List the 4 stages of infection (IPIC)
4,000-10,000 cells/mm3
Normal WBC is _____ to ____ mm3
teaching
Nurses are responsible for ______ patients about infection prevention and control practices at home
a. altered nutrition b. decreased tissue perfusion c. infection d. age e. impaired mobility f. moisture g. alteration in level of consciousness h. impaired sensory perception of pain and pressure i. friction and shear
Select following of which can cause pressure ulcers (SATA) a. altered nutrition b. decreased tissue perfusion c. infection d. age e. impaired mobility f. moisture g. alteration in level of consciousness h. impaired sensory perception of pain and pressure i. friction and shear
c. disinfecting hands immediately after removing gloves.
Standard precautions mandate a. rinsing gloves that become visibly soiled during use. b. using antimicrobial soap for routine hand washing. c. disinfecting hands immediately after removing gloves. d. keeping gloves on when touching environmental surfaces.
degree of resistance. age, nutritional status, chronic disease, trauma, smoking
Susceptibility depends on the individual's degree of ________ to pathogens. What are some risk factors?
A. create and maintain a micro-organism-free environment.
The goal of surgical asepsis is to A. create and maintain a micro-organism-free environment. B. kill all micro-organisms on all instruments involved in a procedure. C. reduce the presence of pathogenic organisms in the environment. D. minimize exposure to the patient's blood during an invasive procedure.
unwashed hands
The mode of transmission for infection usually comes from...
40-52%
The normal range of Hct (hematocrit) is ____ to ____ %
M: 13 to 18 g/dL F: 12-15 g/dL
The normal range of Hgb (hemoglobin) for males are ___ to ___ grams per deciliter (g/dL) and females are _____ to _____ g/dL
4.2 - 6.1 cells/mcL
The normal range of RBC is ____ to ____ million cells per microlitre (cells/mcL)
b. Prevent injury to skin and surrounding tissues. d. Reduce injury to the skin. e. Reduce injury to underlying tissues. f. Restore skin integrity. Optimal outcomes are to prevent injury to skin and tissues, reduce injury to skin, reduce injury to underlying tissues, and restore skin integrity. Asking the client's perceptions and whether expectations are being met allows one to obtain information regarding the experience, but these are not actual measurable outcomes.
The nurse is caring for a client with a Stage III pressure ulcer. Which of the following goals, when met, indicate progression toward healing? (Select all that apply) a. Client's expectations will be met. b. Prevent injury to skin and surrounding tissues. c. Client's perception of interventions will be obtained. d. Reduce injury to the skin. e. Reduce injury to underlying tissues. f. Restore skin integrity.
d. Adjusting to retirement, deaths of family members, and decreased physical strength Challenges faced in older adulthood include adjusting to retirement, deaths of family members, and decreased physical strength. Challenges faced in young adulthood include selecting a vocation, becoming financially independent, and managing a home. Challenges faced in middle adulthood include developing leisure activities, preparing for retirement, and resolving empty-nest crisis.
When developing a care plan for an older adult, the nurse should consider what challenges generally faced by clients in this age group? a. Selecting vocation, becoming financially independent, and managing a home b. Developing leisure activities, preparing for retirement, and resolving empty-nest crisis c. Managing a home, developing leisure activities, and preparing for retirement d. Adjusting to retirement, deaths of family members, and decreased physical strength
D. grasp only the inside of the glove with your ungloved hand.
When donning sterile gloves using the open-gloving method, it is important to remember to A. ask another team member to assist with donning gloves. B. choose a pair of gloves at least one size smaller than usual. C. grasp only the underside of the cuff with your ungloved hand. D. grasp only the inside of the glove with your ungloved hand.
c. place a mask on the client to limit the spread of micro-organisms into the surgical wound Placing a mask prevents contamination Keeping tissues close by for the client to use allows contamination for surgical wound.
When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing the sterile field? a. keep sterile field at least 6 ft away from the client's bedside b. instruct the client to refrain from coughing and sneezing during the dressing change c. place a mask on the client to limit the spread of micro-organisms into the surgical wound d. keep a box of facial tissues nearby for the client to use during the dressing change
B. Holding the sterile pack below waste or table level
When opening a sterile pack, which of the following actions would compromise the sterility of the instruments and supplies inside the pack? A. Allowing movement of team members around the field B. Holding the sterile pack below waste or table level C. Keeping sterile items away from the edge of the table D. Opening the sterile package just prior to the procedure
C) Ask the patient in what order she typically performs her morning routine
When planning morning hygiene care for a postoperative patient, which of the following actions should the nurse include? A) Inform the patient when morning hygiene care is provided at the hospital B) Schedule to provide care to the patient and her roommate at the same time C) Ask the patient in what order she typically performs her morning routine D) Plan to provide care before the next scheduled dose of pain medication
deep tissues
When resident organisms enter invasive procedures, they enter the ____ tissues.
No; that is a falling hazard
When walking with a crutch, it is fine to wear flip flops. (Y/N)
B. The area under each fingernail
Which area of the hands require special attention before you begin a surgical hand scrub? A. The area between each finger B. The area under each fingernail C. The palm of each hand D. The back of the hands
c. Generates new levels of awareness Adults 31 to 45 generate new levels of awareness. Having perceptions based on reality and assuming responsibility for actions indicate socialization development - not cognitive development. Demonstrating maximum ability to solve problems and learning new skills occur in young adults ages 20 to 30.
Which behavior by a 40 year old client indicates adult cognitive development? a. Has perceptions based on reality b. Assumes responsibility for actions c. Generates new levels of awareness d. Has maximum ability to solve problems and learn new skills
a. Its use take less time than washing with soap/water does
Which of the following is an advantage of using alcohol-based gel? a. Its use take less time than washing with soap/water does b. It removes gross contamination better than soap/water does c. Its protective nature reduces the need for frequent hand washing d. It provides adequate protection before surgical applications
a. Consider that nonverbal cues, such as eye contact, may have a different meaning in different cultures. b. Respect the client's cultural beliefs. c. Ask the client if there are cultural or religious requirements that should be considered when planning care. Nonverbal cues may have different meanings in different cultures. In one culture, eye contact is a sign of disrespect; in another, eye contact shows respect and attentiveness. The nurse should always respect the client's cultural beliefs and ask if he has cultural requirements. This may include food choices or restrictions, body coverings, or time for prayer. The nurse should attempt to understand the client's culture; it is not the client's responsibility to understand the nurse's culture. The nurse should never impose her own beliefs on her clients. Culture influences a client's experience with pain. For example, in one culture pain may be openly expressed whereas in another culture it may be quietly endured.
Which of the following nursing actions are appropriate when caring for a client whose cultural background is different from the nurse's? (Select all that apply) a. Consider that nonverbal cues, such as eye contact, may have a different meaning in different cultures. b. Respect the client's cultural beliefs. c. Ask the client if there are cultural or religious requirements that should be considered when planning care. d. Explain the nurse's beliefs so that the client will understand the differences. e. Understand that all cultures experience pain in the same way.
c. Petroleum based hand lotion
Which product can affect the permeability of gloves? a. Antimicrobial soap and water b. Alcohol based antiseptic gel c. Petroleum based hand lotion d. Water based hand lotion