Nur 204 Exam 1 (Chapters 26,27,32,33)

diabetic

- no lotion - no soaking feet - no hot water (neuropathy)

How much soap should be applied when washing hands?

1 tsp (5mL)

Fever

100.4 +

Narcolepsy

A chronic neurological disorder that affects the brain's ability to control sleep-wake cycles, leading to sudden and uncontrollable episodes of falling asleep during the day.

Compassion Fatigue

A condition characterized by emotional and physical exhaustion and a reduced ability to empathize with others, often experienced by healthcare professionals due to the demands of their work.

Halitosis

A medical term for bad breath, often caused by poor oral hygiene, certain foods, or underlying health conditions.

Sleep Apnea

A sleep disorder characterized by pauses in breathing or shallow breaths during sleep, often leading to poor sleep quality and daytime fatigue.

Stress

A state of mental or emotional strain or tension resulting from adverse or demanding circumstances, often accompanied by physical symptoms such as elevated heart rate and muscle tension.

ADLs

Activities of daily living, including tasks such as bathing, dressing, toileting, and eating, which are essential for maintaining personal hygiene and independence.

Systemic Infection (Sepsis)

An infection in which pathogens invade the bloodstream or lymphatic system, spreading throughout the body and causing a systemic inflammatory response.

Healthcare Acquired Infection

An infection that is acquired from a healthcare setting, such as a hospital or clinic, rather than from the community.

Localized Infection

An infection that is limited to a specific area of the body, such as a wound or abscess.

Secondary Infection

An infection that occurs in a person who is already infected with another microorganism, such as a virus or bacteria.

Endogenous Infection

An infection that occurs when the body's own microorganisms, such as bacteria or fungi, multiply and cause illness.

Pandemic

An outbreak of a disease that occurs over a wide geographic area and affects an exceptionally high proportion of the population, often on a global scale.

Methods to Break the Chain of Infection

Procedures and practices aimed at interrupting the transmission of infectious agents, such as handwashing, disinfection, and the use of personal protective equipment (PPE).

1. The nurse is caring for a patient who has been diagnosed with methicillin-resistant Staphylococcus aureus located in her incision. What transmission-based precautions will the nurse implement for the patient? a. Private room b. Private, negative-airflow room c. Mask worn by the staff when entering the room d. Mask worn by the staff and the patient when leaving the patient's room

Answer: a A private room decreases the chance of another patient contracting the infection. The other precautions (i.e., private room with negative airflow, mask worn by staff when entering the room, and mask worn by staff and patient when leaving the patient's room) are airborne precautions, which are not necessary in managing this patient.

Which action by a female patient lets the nurse know the patient has understood perineal care teaching? a. The patient washes her perineum with a circular motion beginning at the urinary meatus. b. The patient washes her perineum from front to back using a clean washcloth. c. The patient washes her perineum from back to front with long, firm strokes. d. The patient washes her perineum lightly to prevent tissue damage.

Answer: b The female perineum is always washed from front to back, washing the area near the urinary meatus first and working back to the anus to avoid introducing organisms into the urinary tract. A circular motion is used for a male patient, washing around the urinary meatus first and then washing down the shaft of the penis. Firm strokes can be used so that the area is well cleaned.

Which safety precaution is a priority for the nurse when bathing a patient with peripheral neuropathy? a. Keeping the top two side rails up during the bath b. Checking the bath water temperature before the bath c. Encouraging independence with perineal care during the bath d. Facilitating range-of-motion exercises and dangling before the bath

Answer: b The patient with peripheral neuropathy may not be able to distinguish extremes of hot and cold. To prevent burns from extremely hot water, the nurse checks the water temperature before beginning the bath and each time clean water is obtained. It is important to keep the top two side rails up when not at the bedside to facilitate turning and positioning. Facilitating range-of-motion exercises and as much independence as possible is important for all patients rather than being a specific safety concern for the patient with peripheral neuropathy. Dangling is important to implement with patietns who have been bedridden and may experience orthostatic hypotension.

Of the following hospitalized patients, who is most at risk for acquiring a health care-associated infection? a. A 60-year-old who smokes two packs of cigarettes per day b. A 40-year-old who has an indwelling urinary catheter in place c. A 65-year-old who is a vegetarian and slightly underweight d. A 60-year-old who has a white blood cell count of 6000

Answer: b Hospital-acquired infections are associated with indwelling urinary catheters. A normal white blood cell count, smoking cigarettes, or being a vegetarian has not been associated with hospital-acquired infections.

5. The nurse is caring for a patient who had abdominal surgery and has developed an infection in the wound while hospitalized. Which agent is most likely the cause of the infection? a. Virus b. Bacterium c. Fungus d. Spore

Answer: b The cause of an infection in the surgical wound in a hospitalized patient who has had abdominal surgery is most likely bacteria because it is present on the skin as normal flora. Fungi and spores are the focus of removal during the surgical preparation. Viruses are target specific and do not usually live on the skin.

Which actions by the nurse concerning oral care for an unconscious patient are considered safe? (Select all that apply.) a. Performing oral care with the patient in a supine position b. Performing oral care with the patient turned to the side c. Installing suction equipment at the bedside d. Providing oral care every 2 hours e. Using a hard-bristle toothbrush

Answer: b, c, d Oral care on an unconscious patient is performed with the patient turned to one side so that fluid can drain out of the side of the mouth. Suction equipment is used to remove fluid and secretions during oral care on an unconscious patient. Oral care should be provided at least every 2 hours for patients who are unconscious, receiving nothing by mouth (NPO), intubated, or receiving oxygen by a mask. An unconscious patient may aspirate if oral care is done in the supine position. A hard-bristle brush may damage the oral mucosa.

An alert and oriented elderly male patient has been admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease (COPD). He is unshaven, has unkempt hair, and has a foul body odor. Asking which hygiene-related assessment question is a priority for the nurse? a. "Do you have friends or family nearby?" b. "Can you raise your arms up to brush your teeth?" c. "Do you become short of breath during your shower?" d. "Are you able to get in and out of your bed at home?"

Answer: c Knowing the COPD patient's activity tolerance helps the nurse formulate a plan for ongoing hygiene care in the hospital and after discharge. Having friends and family nearby may be helpful, but until the activity tolerance is known, his need for outside assistance is not known. A complete assessment of physical capabilities, including his ability to brush his teeth and whether he can get in and out of bed, is important after his activity tolerance has been assessed.

The nurse on a medical floor in a hospital just completed a bed bath. The nurse should take what action before leaving the patient's room? a. Place the call light within reach so the patient can call for help if needed, and leave the bed as it was during the bath. b. Lower the bed to its lowest position, raise all four side rails so that the patient does not fall out of bed, and place the call light within reach. c. Lower the bed to its lowest position, raise the top two side rails to assist the patient in turning and positioning, and place the call light within reach. d. Leave the bed in a position that is comfortable for the caregiver because more care will be needed, raise the top two side rails, and place the call light within reach.

Answer: c The bed is always left in the lowest position so that it is closer to the floor. The top two side rails aid the patient in turning and positioning. The call light is placed within reach of the patient so that the nurse can be called if needed. Leaving the bed in a working or higher position increases the danger of falling if the patient tries to get out of bed. Raising all four side rails is considered a restraint.

The nurse is providing patient education on infection prevention. Which definition of an infection does the nurse use as a teaching point? a. An illness resulting from living in an unclean environment b. A result of lack of knowledge about food preparation c. A disease resulting from pathogens in or on the body d. An acute or chronic illness resulting from traumatic injury

Answer: c A disease resulting from pathogens in or on the body is the definition of an infection. An illness resulting from living in an unclean environment, from lack of knowledge about food preparation, or from trauma can lead to an infection but does not define an infection.

A patient develops food poisoning from contaminated food. What is the means of transmission for the infectious organism? a. Direct contact b. Vector c. Vehicle d. Airborne

Answer: c Contaminated food is a vehicle for transmitting an infection. Direct contact requires close proximity between the susceptible host and an infected person. A vector is a nonhuman carrier, such as an insect or animal. In airborne transmission, the organism is carried through the air on a small droplet or dust particles.

What is the proper order of removal of soiled personal protective equipment (PPE) when the nurse leaves the patient's room? a. Gown, goggles, mask, gloves, and exit the room b. Gloves, wash hands, remove gown, mask, and wash hands c. Gloves, gown, wash hands, goggles, mask, and wash hands d. Goggles, mask, gloves, gown, and wash hands

Answer: c Gloves are removed before the rest of personal protective equipment because they usually are the most contaminated. Gowns are removed by untying the waist and then the neck and grasping inside the neck. Hand hygiene is performed. Protective eyewear or goggles are removed next by grasping them by the earpieces. The mask is removed last because it prevents the spread of respiratory microorganisms. Hands should be washed thoroughly after the equipment has been removed.

A new patient is admitted to a medical unit with Clostridium difficile. Which type of precautions or isolation does the nurse know is appropriate for this patient? a. Airborne precautions b. Droplet precautions c. Contact precautions d. Protective isolation

Answer: c Contact precautions are used with C. difficile because transmission of this contagious disease is possible through contact with the patient or with the equipment or items in the patient's room. Airborne precautions are used when a contagious disease is spread by small droplets that remain suspended in the air for a long period. Droplet precautions are used when a disease is spread by large droplets in the air. Protective isolation is used for patients who are immunosuppressed.

A nurse is preparing to change a sterile dressing and has put on a pair of sterile gloves. To maintain surgical asepsis, what else must the nurse do? a. Keep the amount of splashes on the sterile field to a minimum. b. If a sneeze is imminent, cover the nose and mouth with a gloved hand. c. With a moist saline sponge, use the dominant hand to clean the wound and then apply a dry dressing. d. Regard the outer 1 inch of the sterile field as contaminated.

Answer: d Considering the outer 1 inch of the sterile field as contaminated is a principle of sterile technique. Moisture contaminates the sterile field. Sneezing or coughing would contaminate the sterile glove and necessitate replacing the contaminated glove with a new sterile one. The hand used to clean the wound would not be used to apply a dry dressing. The hand would have to be regloved.

Of the following assessment findings, which cues indicate to a nurse that a patient has a surgical site infection? (Select all that apply.) a. Redness or warmth at the affected site b. Purulent drainage at the incision site c. Tenderness and localized pain d. Wound with well-approximated edges e. White blood cell count 6500 cells/mm3

Answers: a, b, c, Purulent drainage, tenderness, localized pain, and redness or warmth are results of the inflammatory response to an infection. Well-approximated edges are a desired outcome of wound healing. The normal white blood count for adults is 5000 to 10,500 cells/mm3.

Stress Hormones

Chemicals released by the body in response to stress, which can trigger the 'fight or flight' response and lead to increased metabolism and heart rate.

Droplet Precaution

Infection control measures designed to prevent the transmission of pathogens that are transmitted through respiratory droplets, such as coughing or sneezing, over short distances.

Airborne Precaution

Infection control measures implemented to prevent the spread of airborne infectious agents, such as tuberculosis or measles, over longer distances, often requiring specialized negative pressure rooms.

Four Types of Infectious Agents

The four main categories of microorganisms that can cause infection: bacteria, viruses, parasites, and fungi.

Integumentary System/Skin Functions

The functions of the skin, including protection against infection, regulation of body temperature, sensation transmission, and the production of vitamin D.

Diabetic Foot Care

The importance of proper foot care for individuals with diabetes, including regular inspection, appropriate footwear, and the need for professional nail trimming by a podiatrist to prevent complications.

Mode of Transmission

The means by which an infectious agent is spread from one person to another, such as through direct contact, airborne particles, or contaminated objects.

Epidemic

The occurrence of a disease or condition in a community or region that is clearly in excess of normal expectancy, often affecting a large number of people.

Safety in Patient Care

The paramount consideration of ensuring the safety and well-being of patients before, during, and after any healthcare procedure or intervention.

Oral Hygiene in Side Lying Position

The practice of providing oral care to an unconscious patient by positioning them on their side to prevent aspiration and ensure effective cleaning of the oral cavity.

Delegating Bed Bath

The process of assigning the task of giving a bed bath to a designated healthcare assistant, with the expectation that they will report any concerns, incomplete portions, or signs of skin breakdown.

Oral Hygiene Frequency

The recommended practice of cleaning the teeth and mouth at least twice a day using a soft toothbrush, particularly important for patients who are not intubated or receiving oxygen therapy.

Appropriate Biomechanics

The use of correct body mechanics and positioning to prevent injury and strain, such as adjusting the bed height to ensure proper ergonomics when providing patient care.

48. The nurse is preparing to give a full bed bath to a client. Which question is most important for the nurse to ask the client before beginning the bed bath? a. "Do you have any allergies?" b. "Will you be able to wash your own hair?" c. "Are there any areas you want us to spend more time bathing?" d. "Do you have any preferences regarding how we help you bathe?"

a. "Do you have any allergies?" Bed baths involve applying water and a cleansing agent, such as soap or chlorhexidine gluconate (CHG), to the skin. The nurse needs to first inquire about any allergies to ensure that the client is not allergic to the cleansing agent that will be used. Although options 2, 3, and 4 are appropriate questions to ask the client, the determination of any client allergies is the most important client data to obtain before beginning the bed bath.

16. The nurse is providing education to a patient who is being discharged home on antibiotic therapy. Which statement(s) by the patient indicates further education is needed? (Select all that apply.) a. "I should take antibiotics every time I am sick." b. "I should take all antibiotics as prescribed." c. "I should save all unused antibiotics." d. "I should stop taking antibiotics when I feel better." e. "If I develop a rash while taking these I will call the provider."

a. "I should take antibiotics every time I am sick." c. "I should save all unused antibiotics." d. "I should stop taking antibiotics when I feel better." The overuse of antibiotics and inappropriate use, such as not completing prescriptions and sharing antibiotics, has led to increased resistance. Taking antibiotics as prescribed helps to ensure the infection will be treated correctly. A rash may indicate an allergic reaction and the patient needs to report this to the provider.

28. The nurse knows that standard precautions are indicated for which group(s) of patients? (Select all that apply.) a. All patients b. Patients with HIV c. Patients with MRSA d. Patients with tuberculosis e. Patients who are bleeding

a. All patients e. Patients who are bleeding The nurse can take steps at any link in the chain to halt the spread of infection. Standard precautions are used with all patients to limit direct exposure to blood and body fluids. The other choices are additional precautions such as airborne precautions are used with patients who have diseases such as tuberculosis and contact precautions with patients who have MRSA.

3. The nurse correctly identifies which patient as having the greatest risk for infection? a. An 80-year-old male with an enlarged prostate b. A 24-year-old female long-distance runner c. A 50-year-old obese male d. A 40-year-old sexually active female

a. An 80-year-old male with an enlarged prostate The 80-year-old male has more risk factors because he is elderly and has increased risk of urinary tract infection related to prostate enlargement, so he has two risk factors. A 24-year-old female runner is likely healthy with no additional risk factors. The 50-year-old obese male has one additional risk factor. The 40-year-old sexually active female may not have additional risk factors if she is using protection and does not have multiple partners.

18. Which tool is used by the nurse to determine risk for impaired skin integrity? a. Braden scale b. Glasgow scale c. Vanderbilt scale d. MMSE scale

a. Braden scale The Braden scale is used to determine risk for impaired skin integrity: The Glasgow is a coma scale, the Vanderbilt is a behavior scale, and the MMSE is the mini-mental exam to determine cognitive status.

37. What action by the nurse is inappropriate regarding denture care? a. Carrying the dentures to the sink wrapped in a paper towel b. Placing a towel in the sink and brushing the dentures over the towel c. Brushing the dentures as the nurse would the teeth of a conscious patient d. Applying adhesive, then inserting upper and then lower dentures

a. Carrying the dentures to the sink wrapped in a paper towel Dentures should not be wrapped in a paper towel; they should be placed in the denture cup to carry them to the sink. The towel prevents the dentures from being damaged if the teeth are dropped. The nurse can brush the dentures as she would the teeth of a conscious patient. Apply denture adhesive (if used) and insert the dentures, inserting first the upper and then the lower plates, using 4 X 4 inch gauze.

27. When the patient is diagnosed with pertussis, which isolation precaution should the nurse implement? a. Droplet b. Airborne c. Contact d. Protective

a. Droplet Droplet precautions are used when known or suspected contagious diseases can be transmitted through large droplets suspended in the air. Contact precautions are used when a known or suspected contagious disease may be present and is transmitted through direct contact with the patient or indirect contact with items in the patient's environment. Airborne precautions are used when known or suspected contagious diseases can be transmitted by means of small droplets or particles that can remain suspended in the air for prolonged periods.

5. When teaching a student nurse about removing PPE, the nurse would include which correct order of equipment removal? a. Gloves, eyewear, gown, and mask b. Mask, eyewear, gown, and gloves c. Gown, mask, eyewear, and gloves d. Gloves, gown, mask, and eyewear

a. Gloves, eyewear, gown, and mask When removing PPE, gloves, which are contaminated, are removed first to prevent contamination of the face and eyes during removal of the mask and to prevent spread of microorganisms. Eyewear should then be removed, followed by the gown and finally the mask.

38. The nurse is assisting a patient to insert contacts and a contact is dropped. What action should occur next? a. Moisten the finger with lens solution and gently touch it to pick it up. b. Moisten the contact lens with tap water and pick it up. c. Pick it up and insert the contact lens. d. Discard the contact lens.

a. Moisten the finger with lens solution and gently touch it to pick it up. If a lens is dropped, do the following: (1) moisten a finger with the lens solution, and then gently touch the lens with the moistened finger to pick it up. (2) Clean, rinse, and disinfect the lens to avoid a potential eye infection from any microorganisms that might have adhered to the lens. The contact lens does not need to be discarded and tap water should not be used for contact lens.

4. The nurse knows which skill does not require the use of sterile technique? a. NG tube insertion b. Foley catheterization c. Tracheostomy care d. PICC line insertion

a. NG tube insertion NG tube insertion requires a clean, not sterile, technique as the gastrointestinal tract (stomach) is not sterile. Use strict aseptic technique when inserting an intravenous (IV) or Foley catheter and when performing suctioning of the lower airway.

11. The nurse uses what term to identify a disease-causing organism? a. Pathogen b. Normal flora c. Germ d. Microorganism

a. Pathogen Infectious agents include any disease-causing agent and are called pathogens. They include bacteria, fungi, viruses, and parasites. Normal flora is a group of non-disease-causing microorganisms that live in or on the body. Germ is a term used for microorganism. A microorganism is bacteria, fungi, or protozoa.

42. The nurse should avoid soaking the feet of which patient population? (Select all that apply.) a. Patients with peripheral vascular disease b. Patients with a stroke c. Patients with diabetes d. Patients with arthritis e. Patients who are malnourished

a. Patients with peripheral vascular disease b. Patients with a stroke c. Patients with diabetes Soaking the feet of patients with peripheral vascular disease, cardiovascular disease such as strokes and diabetes are contraindicated because it may cause skin breakdown or infection. Patient with arthritis or malnourished have no contraindications to having their feet soaked.

41. Regarding perineal care, which nursing actions are appropriate? (Select all that apply.) a. The nurse applies gloves prior to performing perineal care. b. The nurse ignores the erection of a male patient during perineal care. c. The nurse documents the perineal care. d. The nurse only completes perineal care with daily bathing. e. The nurse can delegate perineal care.

a. The nurse applies gloves prior to performing perineal care. b. The nurse ignores the erection of a male patient during perineal care. c. The nurse documents the perineal care. e. The nurse can delegate perineal care. The nurse uses standard precautions (gloves) whenever contact with body fluids is expected. A male patient may have an erection during care, which is a normal response with tactile stimulation. The care provider can ignore the erection and continue with the procedure or return later to complete the care, depending on the comfort level and the situation. Documentation is part of hygienic care. Note any redness, drainage, odor, edema, or skin changes. Perineal care is provided during a bath or shower but may be necessary more frequently, especially in incontinent patients. Perineal care can be delegated.

30. The nurse knows that which statement is true regarding the importance of hygiene? a. The nurse can assess other body systems during the bath. b. UAPs perform hygiene because there is no benefit of nurses doing this care. c. The mucous membranes of the lips, nostrils, anus, vagina, and urethra are not a part of the integumentary system when providing hygiene. d. The main purpose of bathing is to decrease the patient's body odor.

a. The nurse can assess other body systems during the bath. The bath is an excellent opportunity for the nurse to assess multiple body systems. Although the UAP can perform hygiene, there is benefit to the nurse doing it because of the ability to assess the patient. The mucous membranes are a part of the integumentary system, and bathing cleanses the skin, reduces odor, provides comfort, and contributes to the patient's health and well-being.

22. The nurse is teaching a group of patients about diseases that are transmitted by ticks. Which term would the nurse use when identifying the function of a tick in spreading disease? a. Vectors b. Bacteria c. Viruses d.Fungi

a. Vectors Vectors carry pathogens from one host to another. Bacteria are single-cell organisms. Viruses are the smallest organisms. Fungi are single-cell organisms that can cause infection.

avoid

avoid soaking a diabetic, stroke, peripheral vascular disease patient's feet

43. The nurse notes that a trauma patient has multiple tangles in the hair. Which actions taken by the nurse are appropriate? (Select all that apply.) a. Work the tangles to the ends of the hair, then trim with scissors. b. Apply warm water and conditioner. c. Apply detangler as available. d. Use a comb or fingers to work through tangles. e. Cut the tangles out if working on them agitates the patient.

b. Apply warm water and conditioner. c. Apply detangler as available. d. Use a comb or fingers to work through tangles. Apply warm water and a conditioner or a detangler, if available, to release tangles and avoid injury to the scalp. Use a comb and/or fingers to work through the tangles individually before shampooing. The nurse avoids cutting the patient's hair unless first asking the patient's permission.

9. The nurse knows that which areas of the patient's body are at increased risk of excoriation? (Select all that apply.) a. Exposed areas such as the face b. Areas exposed to stool c. Skin on skin areas d. Area under pendulous breasts e. Under an abdominal fold

b. Areas exposed to stool c. Skin on skin areas d. Area under pendulous breasts e. Under an abdominal fold Excoriation (red, scaly areas with surface loss of skin tissue) occurs in patients whose skin is exposed to bodily fluids such as stool, urine, or gastric juices. Excoriation also occurs in areas where skin rests on skin, such as in the axilla (armpit); under large, pendulous breasts; or in

52. The nurse is assisting the assistive personnel (AP) in cleaning a room that was infected with Clostridium difficile. To ensure that all surfaces are evenly disinfected, which cleaning solution would the nurse plan to use? a. Soap and water b. Bleach solution c. Alcohol-based solution d. Ammonia-based disinfectant

b. Bleach solution Clostridium difficile is a bacterium that disrupts healthy normal bowel flora. Clostridium difficile is difficult to destroy. A 10% bleach solution or a disinfectant that is sporicidal needs to be used to ensure that all equipment is properly disinfected. Soap and water, alcohol-based solutions, and ammonia-based disinfectant are not effective in eliminating this infection (the spores).

26. Which isolation precaution should the nurse implement for the patient who has been diagnosed with hepatitis A? a. Airborne b. Contact c. Droplet d. Protective

b. Contact Contact precautions are used when a known or suspected contagious disease may be present and is transmitted through direct contact with the patient or indirect contact with items in the patient's environment. Airborne precautions are used when known or suspected contagious diseases can be transmitted by means of small droplets or particles that can remain suspended in the air for prolonged periods. Droplet precautions are used when known or suspected contagious diseases can be transmitted through large droplets suspended in the air. Protective isolation is used for patients who have compromised immune systems.

40. The nurse is bathing a patient and notes reddened skin above the coccyx. Which actions by the nurse are appropriate? (Select all that apply.) a. Apply a barrier cream and massage the area. b. Document the findings. c. Position the patient to relieve pressure on coccyx. d. Report the area to the charge nurse. e. Report the new finding to the provider.

b. Document the findings. c. Position the patient to relieve pressure on coccyx. d. Report the area to the charge nurse. e. Report the new finding to the provider. Gently wash any reddened or swollen areas and pat them dry. Use clean, nonsterile gloves as needed to comply with standard precautions. Document the findings from the assessment and report them to the provider, charge nurse, or other appropriate personnel per agency policies. Avoid massaging reddened areas on the skin during the bath. Further tissue breakdown can occur if reddened areas are massaged.

34. The nurse is preparing to give a patient a complete bed bath. What area of the body should be bathed first? a. Hands b. Eyes c. Face d. Arms

b. Eyes The nurse should start washing the patient's eye area, using a washcloth without soap, followed by the patient's face, hands, and arms.

1. The nurse recognizes which term to identify the second line of defense that leads to local capillary dilation and leukocyte infiltration? a. Normal flora b. Inflammatory response c. Immune response d. Humoral immunity

b. Inflammatory response The second line of defense is the inflammatory response. Inflammation is a local response to cellular injury or infection that includes capillary dilation and leukocyte infiltration. Normal flora is the body's first line of defense. The immune response is the body's attempt to protect itself from foreign and harmful substances. Humoral immunity is a defense system that involves white blood cells (B lymphocytes) that produce antibodies in response to antigens or pathogens circulating in the lymph and blood.

14. The nurse recognizes which situation to be inappropriate to use alcohol-based hand sanitizer? a. Patient with pneumonia b. Patient with Clostridium difficile c. Status post-appendectomy d. Patient with HIV

b. Patient with Clostridium difficile Soap and water must be used to thoroughly clean hands if there is any visible soiling or dirt and with certain infections such as Clostridium difficile and vancomycin-resistant enterococci when preparing for a sterile or surgical procedure, before and after eating, and after using the restroom. In the other situations, a hand sanitizer is as effective as soap and water.

45. Two nurses are leaving the room of a client whose care required them to wear a gown, mask, and gloves. Which action by these nurses could lead to the spread of infection? a. Taking off the gloves first before removing the gown b. Removing the gown without rolling it from inside out c. Washing the hands after the entire procedure has been completed d. Removing the gloves and then removing the gown using the neck ties

b. Removing the gown without rolling it from inside out The gown must be rolled from inside out to prevent the organisms on the outside of the gown from contaminating other areas. Gloves are considered the dirtiest piece of equipment and therefore must be removed first. Hands must be washed after removal of the protective garb to remove any unwanted germs still present. Ungloved hands need to be used to remove the gown to prevent contaminating the back of the gown with germs from the gloves.

10. The nurse is demonstrating cultural sensitivity in performing perineal care when carrying out which actions? (Select all that apply.) a. The male nurse delegates perineal care of a female patient to the female UAP. b. The male nurse asks a female patient if she would prefer a female to perform care. c. The nurse approaches the care in a sensitive, professional manner. d. The nurse assesses cultural preferences of the patient prior to care. e. The nurse provides care quickly and in a matter of fact manner.

b. The male nurse asks a female patient if she would prefer a female to perform care. c. The nurse approaches the care in a sensitive, professional manner. d. The nurse assesses cultural preferences of the patient prior to care. The nurse assesses patient backgrounds and provides hygienic care in a manner that is sensitive to the differences in habits and customs. This includes asking the patient about their preferences and not assuming what their preferences will be. A female patient may be comfortable with a male nurse performing perineal care. The nurse should not perform the care without asking first and should not preform the task quickly.

20. The nurse and UAP are making an occupied bed together. Which action by the nurse is incorrect? a. The nurse asks and assists the patient to turn toward the UAP and loosens the fitted sheet and rolls it in toward the patient. b. The nurse rolls dirty linens to the side then places the linens on the floor while finishing. c. The nurse tucks the clean bottom sheet under the cleaner underside of the dirty linens. d. The nurse wears gloves to remove dirty linens.

b. The nurse rolls dirty linens to the side then places the linens on the floor while finishing. Bed linens should be placed in the linen hamper, not on the floor, after they are removed from the bed. The patient turns to each side while the bed linens are changed, and the nurse wears gloves.

24. The nurse is caring for a patient who is comatose. When preforming oral hygiene, which interval is most appropriate? a. Every shift b. Twice daily c. Every 4 hours d. Daily

c. Every 4 hours Oral care should be performed every 4 hours to prevent the colonization of bacteria. Less often than every 4 hours is not effective.

47. The nurse is reviewing dental care with a client who is edentulous (lacking teeth) and wears dentures. Which client statement indicates an understanding of proper dental care? a. "Since I have no teeth, I do not need to brush my mouth." b. "I need to use hot water when cleaning my dentures to kill bacteria." c. "I will remove my dentures before bed and keep them in my labeled denture cup covered with water." d. "When I am not wearing my dentures during the day, I can keep them in the denture cup with no water, as they should only be in water at night."

c. "I will remove my dentures before bed and keep them in my labeled denture cup covered with water." Denture care and oral hygiene are important in the care of the edentulous client who wears dentures. Clients may think that since they no longer have teeth, they no longer need to brush their gums. Educate clients that proper brushing is still essential to maintain good gum health. Therefore, option 1 is incorrect. Dentures need to be cleaned on a regular basis to avoid gingival infection and irritation. Whenever the dentures are removed, they need to be stored in the client's labeled denture cup and covered with water to prevent drying out and warping of the dentures. Therefore, option 4 is incorrect. Dentures need to be cleaned in lukewarm, or tepid, water to prevent damaging or warping the dentures. Therefore, option 2 is incorrect. Option 3, the correct answer, indicates client understanding, as dentures need to be removed at night to provide the gums rest and prevent bacteria buildup. The dentures need to be stored in the client's labeled denture cup and covered with water.

51. Precautions are used when caring for a client with Clostridium difficile. The nurse is planning on providing morning care for the client and needs to obtain which specific protective equipment for this infection? a. Gloves and a gown b. Gloves and a mask c. Gloves, gown, and a mask d. Gloves, gown, mask, and a hair covering

c. Gloves, gown, and a mask Clostridium difficile (C. diff) is an infection that destroys normal bowel flora and leads to increased diarrhea. Contact precautions are used for clients with Clostridium difficile because the infection is in the stool. With contact precautions, the nurse needs to wear gloves and a gown to provide protection from the infection. A mask is not necessary unless another condition that is transmitted via the droplet or airborne routes is present, or if agency policy and procedure mandates the use of a mask.

29. The patient is on protective precautions. The nurse knows which statements are true regarding these precautions? (Select all that apply.) a. A positive-pressure room with a HEPA filtration system is required. b. Special respirator masks should be available and one size fits all. c. No live plants are allowed in the room. d. The patient may eat any foods desired. e. Everyone entering the room wears a mask.

c. No live plants are allowed in the room. e. Everyone entering the room wears a mask. Protective precautions may require a positive-pressure room. No live plants, fresh flowers, fresh raw fruit or vegetables, sushi, or blue cheese may be brought into the room because they may harbor bacteria and fungi. The patient cannot eat just any foods because some are restricted. A mask is required for anyone entering the room and for the patient if leaving the room.

35. The nurse has assisted the patient to wash the hands, face, axillae, and perineal area. What type of bath does the nurse chart? a. Sink bath b. Complete bed bath c. Partial bed bath d. Shower

c. Partial bed bath A partial bed bath is performed when only part of the body is washed. A complete bed bath is for patients who are completely bedridden or are totally dependent on others for care. A shower is usually for patients who are strong enough to shower independently. A sink bath is when the patient washes while standing or sitting in front of a bath basin or sink.

23.A patient admitted after abdominal surgery has a Nursing diagnosis of risk for infection. The nurse identifies which goal to be most appropriate? a. Patient will ambulate length of hallway this shift. b. Patient will consume 20% of meals by the end of the week. c. Patient's incision will be without signs or symptoms of infection at discharge. d. Patient will verbalize need to stop antibiotics medication when symptom free.

c. Patient's incision will be without signs or symptoms of infection at discharge. Maintaining skin integrity is an appropriate goal for this patient to ensure the patient does not develop a wound infection. Ambulating will assist in preventing skin breakdown but getting the patient out of bed, but it is not the priority goal for a patient with an incision. Consuming only 20% of meals will not ensure adequate nutrition and verbalizing the end of antibiotic administration to be when symptoms end is inappropriate. Antibiotics should be taken until the prescription is complete.

15. When the nurse is wearing sterile gloves, which action would result in the gloves becoming nonsterile? a. Fold gloved hands until procedure begins. b. Change a dressing using aseptic technique. c. Place sterile gloved hands below waist. d. Use correct protocol when donning sterile gloves.

c. Place sterile gloved hands below waist. Once the hands have been placed below the waist, they can longer be considered sterile or free from organisms. Asepsis refers to freedom from disease-causing contamination. All other choices maintain asepsis.

17. Excessively dry skin can lead to cracks and openings in the integumentary system. Based on this, what is the most applicable Nursing diagnosis for a patient with excessively dry skin? a. Impaired Health Maintenance b. Risk for Injury c. Risk for infection d. Acute pain

c. Risk for infection Any interruption in the skin, which is the body's first line of defense, can potentially lead to infection. Impaired health maintenance could have dry skin as a symptom. Acute pain and risk for injury are not appropriate.

8. The nurse is caring for a patient with swallowing concerns and decreased level of consciousness. The nurse knows to put the patient in what position for oral care? a. High Fowler's b. Prone c. Side-lying d. Low Fowler's

c. Side-lying The side-lying position should be used to prevent aspiration. The high Fowler's, low Fowler's, and prone position will not prevent aspiration.

13. The nurse understands that which set of vital signs most likely indicates infection? a. T: 98.6 °F (37.0 °C), P: 75 beats/min, R: 18 breaths/min, BP 120/80 mm Hg b. T: 99 °F (37.2 °C), P: 80 beats/min, R: 18 breaths/min, BP: 110/70 mm Hg c. T: 100.5 °F (38 °C), P: 96 beats/min, R: 22 breaths/min, BP: 150/100 mm Hg d. T: 98.9 °F (37.1 °C), P: 66 beats/min, R: 18 breaths/min, BP: 98/62 mm Hg

c. T: 100.5 °F (38 °C), P: 96 beats/min, R: 22 breaths/min, BP: 150/100 mm Hg With infection, temperature will rise and blood pressure will increase along with pulse and respiratory rate.

49. The home health nurse visits a client with suspected scabies. Which precaution would the nurse institute during the assessment of the client? a. Wear gloves only. b. Wear a mask and gloves. c. Wear a gown and gloves. d. Avoid touching the client's home furnishings.

c. Wear a gown and gloves. The Centers for Disease Control and Prevention recommends wearing gowns and gloves for close contact with a client infested with scabies. Masks are not necessary. Transmission via clothing and other inanimate objects is uncommon. Scabies usually is transmitted from client to client by direct skin contact. All contacts that the client has had need to be treated at the same time.

NEVER

cut a patient's toe nails, filling is acceptable. (esp. a diabetic's)

21. The nurse is explaining to the patient why antibiotics are being administered. The answer would be correct if the nurse stated antibiotics are effective against which microorganism? a. Viruses b. Fungi c. Parasites d. Bacteria

d. Bacteria Antibiotics are effective against bacteria, and exact antibiotic sensitivity is tested so that appropriate antibiotics are prescribed. Infections that are caused by fungi are treated with antifungal medications. Certain antiviral medications are used to manage the symptoms of a viral infection. These medications, if given during the early phases of illness, can decrease the amount of time that the patient has viral symptoms. Treatment for parasitic infections varies depending on type of parasite.

25. The nurse is preparing to perform suctioning on a new tracheostomy with the potential for forceful expulsion of secretions and identifies what PPE (personal protective equipment) should be worn? a. Gloves and eyewear b. Gloves, gown, and mask c. Eyewear and gown d. Eyewear, mask, gown, and gloves

d. Eyewear, mask, gown, and gloves Use gloves routinely when blood or body fluid might be present. If splashing is possible, use your nursing judgment about what other PPE might be necessary. Forceful expulsion of secretions would require all PPE—gown, mask, eyewear, and gloves—to provide adequate protection.

44. Contact precautions are initiated for a client with a nosocomial (health care-associated) infection caused by methicillin-resistant Staphylococcus aureus. The nurse prepares to provide colostomy care and would obtain which protective items to perform this procedure? a. Gloves and gown b. Gloves and goggles c. Gloves, gown, and shoe protectors d. Gloves, gown, goggles, and a mask or face shield

d. Gloves, gown, goggles, and a mask or face shield Splashes of body secretions can occur when providing colostomy care. Goggles and a mask or face shield are worn to protect the face and mucous membranes of the eyes during interventions that may produce splashes of blood, body fluids, secretions, or excretions. In addition, contact precautions require the use of gloves, and a gown should be worn if direct client contact is anticipated. Shoe protectors are not necessary.

12. What response would the nurse provide to correctly identify the most effective method to prevent hospital-acquired infections? a. Use of sterile technique b. Isolation protocols c. Antibiotic use d. Handwashing

d. Handwashing Handwashing is the most effective method to prevent hospital-acquired infections. Sterile technique is only used for certain procedures and isolation protocols are used for patients already infected or for protective isolation in immune-compromised patients and are not used for every patient. Antibiotics are used to treat infections.

50. A client with pulmonary tuberculosis (TB) is on airborne isolation precautions. Which item(s) is essential for the nurse to wear? a. Gloves only b. Fluid shield mask c. Gown, mask, and gloves d. High-efficiency particulate air (HEPA) filter mask

d. High-efficiency particulate air (HEPA) filter mask The hospitalized client with TB is placed on airborne isolation. A HEPA filter mask must be worn whenever the nurse enters the client's room because these masks can remove almost 100% of the small TB particles. This mask must fit snugly around the nose and mouth. Option 1 is an incorrect option; although gloves may be needed, the nurse must wear a HEPA mask. Option 2 is incorrect. The mask must be a HEPA mask. Option 3 is an incorrect choice. The mask must be a HEPA mask, and there is no need for gown and gloves unless a wound, body fluid, or blood is involved.

2. The nurse recognizes that the stethoscope most correctly represents which possible link in the chain of infection? a. Source b. Portal of exit c. Portal of entry d. Mode of transmission

d. Mode of transmission The stethoscope would be a means for the pathogen to travel from source to host. The source is the reservoir or host. The portal of exit is where the pathogen escapes from the reservoir of infection, and the portal of entry is where the microorganism enters the susceptible host.

33. The nurse is providing care to a post-stroke patient on the rehabilitation floor with a nursing diagnosis of Impaired health maintenance. Which goal is most appropriate on day one? a. Patient will ambulate independently twice a day. b. Patient will perform all own ADLs. c. Patient will consume 75% of all meals. d. Patient will begin to perform 25% of own ADLs.

d. Patient will begin to perform 25% of own ADLs. The patient needs to work toward achieving as much independence in self-care as possible; starting with 25% in a post-stroke patient on day one is more achievable than 100%. Ambulating and eating meals are not goals for a problem with self-care.

6. The nurse correctly identifies which patient as having the highest risk for injury related to temperature of water when bathing? a. Patient with asthma b. Patient with attention deficit hyperactivity disorder c. Patient with a stroke d. Patient with diabetes

d. Patient with diabetes Patients with neurologic deficits such as peripheral neuropathy resulting from diabetes may not be able to identify extremes of hot and cold. Patients with attention deficit hyperactivity disorder and asthma are not likely to be injured by temperature extremes. Patients with a stroke may have some alteration in sensation on one side of their body but can compensate by using the other side, and they are at less risk than a patient with diabetes.

7. The nurse is performing perineal care for the uncircumcised patient. Which action does the nurse take? a. Does not move the foreskin. b. Retracts the foreskin, pulling it away from the body. c. Leaves the foreskin retracted, allowing it to return to position naturally after care. d. Retracts the foreskin and returns it to its natural position after cleaning, rinsing, and drying.

d. Retracts the foreskin and returns it to its natural position after cleaning, rinsing, and drying. The foreskin must be returned to its normal position after cleaning to prevent contraction and swelling. It is okay to move the foreskin to clean the penis. To retract the foreskin, gently push it toward the body. It should be returned to its position by the nurse, not left to return on its own.

46. The nurse in a long-term care facility is observing a nursing student provide foot care to a client with diabetes mellitus. Which action by the nursing student would indicate a need for further teaching? a. The nursing student tells the client to avoid soaking the feet. b. The nursing student dries the feet thoroughly, including in between the toes. c. The nursing student advises the client to consult the physician or a podiatrist regarding nail trimming. d. The nursing student applies lotion to the dorsal and plantar surfaces of the feet and in between the toes.

d. The nursing student applies lotion to the dorsal and plantar surfaces of the feet and in between the toes. Clients with diabetes mellitus are at an increased risk for impaired skin integrity related to peripheral neuropathy or vascular insufficiency. The feet are at an increased risk for the development of wounds and some clients may be unable to thoroughly inspect the feet regularly due to impaired mobility or other impairments. Meticulous foot care is necessary to prevent complications. The client's feet would not be soaked to prevent maceration, or skin softening, as this increases the risk of infection. Regarding nail trimming, a podiatrist or a physician's order may be necessary to trim the nails, as a client with diabetes mellitus is at increased risk for infection if the skin were to be accidentally cut. The feet need to be dried thoroughly, with special attention given to the areas between the toes, as skin breakdown or ulcers can go undetected in this area. Lotion needs to be applied to the dorsal and plantar surfaces of the foot. However, it would not be applied between the toes as this area needs to be kept dry. Therefore, option 4 is the action by the nursing student that requires a need for further teaching.

19. What statement by the nurse is true regarding oral care of patients on anticoagulants? a. Use an electric toothbrush daily. b. Avoid oral care. c. Use mouthwash only. d. Use a soft-bristled toothbrush.

d. Use a soft-bristled toothbrush. Oral care is important regardless of medication, but a soft-bristled toothbrush should be used related to increased risk of bleeding for any patient on an anticoagulant. An electric toothbrush is too aggressive, and mouthwash is not adequate.

39. The nurse is asked to shave a patient who is taking warfarin (Coumadin). What is the most appropriate action? a. Refuse to shave the patient because he is on an anticoagulant. b. Shave as usual with a safety razor. c. Offer to wax rather than shave the patient. d. Use an electric razor.

d. Use an electric razor. Patients on anticoagulants should use an electric razor for shaving to avoid bleeding complications. Patients should have the option of shaving if they would like to shave. Waxing may not be an option.

36. When providing the patient with routine hygienic care, which action would the nurse omit? a. Massage the back with lotion b. Oral care with a toothbrush c. Shaving with a disposable razor d.Ear hygiene with cotton-tipped applicators

d.Ear hygiene with cotton-tipped applicators Cotton-tipped swabs or applicators should not be used in the ears for cleaning because this can push wax farther into the ears. A back massage may be given as part of a complete bed bath. Oral care is an essential nursing intervention that provides patient comfort, removes plaque and bacteria, reduces the risk of tooth decay, and decreases halitosis. Oral care includes brushing the teeth and tongue, flossing, rinsing the mouth, and cleaning dentures. Shaving a patient may be part of hygienic care and can be done with a disposable or electric razor.

Lines of defense against infection

first line of defense: normal flora second line of defense: inflammatory response third line of defense: immune response

avoid

massaging reddened areas

passive immunity

receives antibodies from another source (ex. vaccine)

REEDA

redness, edema, ecchymosis, drainage, approximation

virulence

the ability of a pathogen to invade and injure the host