Fundamentals Exam 4 Ch 28 & 50; class notes and practice questions

Factors influencing infection Prevention and control

- Age - Sex (Gender) - Nutritional Status - Stress - Disease process

Labs required before surgery are:

- CBC - Pregnancy test

What labs may be completed pre-operation on every patient?

- CBC - Pregnancy test

Donning steps first and last:

- Gown first - Gloves last

Preop assessment the nurse should take into consideration what?

- How does the patient feel? -What is the patient's perception of the operation? - Smoking status - Social history is NOT IMPORTANT

Nursing diagnosis of a post-operative patient:

- Impaired airway - Impaired skin integrity

Stages of the disease process/infection:

- Incubation - Symptoms - Proliferation - Containment - Resolution

Chain of infection

- Infectious agent - Reservoir: food, O2, water, light - Portal of Exit; skin, resp system, blood - Modes of transmission - Portal of Entry - Host

Anesthesia complications include:

- Malignant hyperthermia - temp regulation - Hereditary

Health promotion includes

- Nutrition - Hygiene - Immunization - Adequate Rest and regular exercise

What are surgical risk factors? (SATA)

- Obstructive Sleep apnea - Obesity - Nutritional status

Nursing Diagnoses for infection or risk for infection are:

- Risk for infection - Impaired Nutritional Status - Impaired tissue integrity

Common nursing diagnoses in surgery patients include:

- Risk for infection - Impaired skin integrity - Impaired airway clearance

Anesthesia effects post surgery include:

- Slows everything down - Bowel function - Catheters are common - Urinary muscles often "forget" how to function (palpate bladder for fullness)

If a patient feels better during their course of antibiotics why should they complete the prescribed course?

- The infection could come back if antibiotics are not completed - MRSA could form

Post anesthesia recovery score

- Used to evaluate patients in Phase 1 - Vital Signs

Two priorities during hand hygiene is to:

-Wash hands below elbow level - Use 4-5 mL soap

In which situations does the nurse wear clean gloves as part of standard precautions? (Select all that apply.) A. In the care of a patient diagnosed with an infectious process B. When the patient is diaphoretic C. During care of each individual under treatment in the facility D. In the presence of urine or stool E. When taking the patient's blood pressure

ANS: A, C, D Rationale:

Put the following steps for removal of protective barriers after leaving an isolation room in order: 1. Untie top, then bottom mask strings and remove from face 2. Untie waist and neck strings of gown. 3. Allow gown to fall from shoulders and discard. Remove gown, rolling it onto itself without touching the contaminated side 4. Remove gloves 5. Remove eyewear or goggles 6. Perform hand hygiene.

ANS: 4, 5, 2, 3, 1, 6 Proper Order: 1. Remove Gloves 2. remove eyewear or goggles 3. Untie waist and neck strings of gown 4. Allow gown to fall from shoulders and discard. remove gown, rolling it onto itself without touching the contaminated side 5. Untie top, then bottom mask strings and remove from face 6. Perform hand hygiene Rationale:

Of the following assessment findings, which signs indicate to a nurse that a patient has a surgical site infection? (Select all that apply.) A. Thick, white drainage in the Jackson-Pratt tubing B. Redness or warmth at the affected site C. Purulent drainage at the incision site D. Temperature 100.4 F (38 C) E. Tenderness and localized pain F. Wound with well-approximated edges G. Purulent drainage at the incision site

ANS: A, B, C, D, E, G

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? (Select all that apply). A. Planning & evaluating control prevention strategies. B. Determining public health priorities. C. Ensuring proper medical treatment. D. Identifying endemic disease. E. Monitoring for common-source outbreaks.

ANS: A, B, C, E Rationale: Reporting of communicable and infectious disease assist with planning and evaluating control and prevention strategies, determining public health policies, ensuring proper medical treatment is available, and monitoring for common-source outbreaks

A nurse is planning care for a client to prevent postoperative atelectasis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Encourage use of incentive spirometer every 2 hours B. Instruct the client to splint the incision when coughing and deep breathing C. Reposition the client every 2 hours D. Administer antibiotic therapy E. Assist with early ambulation

ANS: A, B, C, E Rationale: Use of the incentive spirometer every 2 hours expands the lungs and prevents atelectasis. Incisional splinting with a pillow or blanket supports the incision during coughing or deep breathing, which prevents atelectasis. Repositioning the client every 2 hours will mobilize secretions and allow the client to deep breath and expand the lungs to prevent atelectasis. Antibiotic therapy is used to prophylactically prevent or treat infection and does not prevent atelectasis. Early ambulation expands the lungs through deep breathing and prevents atelectasis

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? (Select all that apply). A. Fever B. Malaise C. Edema D. Pain or tenderness E. Increase in pulse and respiratory rate

ANS: A, B, E Rationale: A fever indicates that the infection is affecting the whole body, and therefore is systemic. Malaise indicates that the infection is affecting the whole body. An increase in pulse and respiratory rate indicates that the infection is affecting the whole body

The nurse is caring for a patient that has a diagnosis of methicillin-resistant Staphylococcus aureus (MRSA). Which of the following infection-control practices should the nurse implement? (Select all that apply.) A. Wear a protective gown when entering the patient's room B. Don a particulate respirator mask when administering medication to the patient C. Ensure that all staff serving the patient's meal trays don gloves prior to delivering of tray D. Instruct all visitors to wear a surgical mask when entering the patient's room E. Use sterile gloves when performing dressing changes F. Use a face shield before irrigating the patient's wounds

ANS: A, C, F Rationale:

Which patient is at greatest risk of complications during surgery? A. 27-year-old with a history of renal disease B. 49-year-old with high blood pressure C. Healthy 70-year-old male D. 23-year-old with a history of DVTs

ANS: A. 27-year-old with a history of renal disease Rationale:

A client with active tuberculosis is admitted to the medical center. The nurse recognizes that admission of this client to the unit will require the implementation by the staff of: A. Airborne precautions B. Droplet precautions C. Contact precautions D. Reverse isolation

ANS: A. Airborne precautions Rationale: A client with active tuberculosis requires airborne precautions. A client with active tuberculosis does not require droplet precautions, as the droplet nuclei of tuberculosis are smaller than 5 micrometers. Contact precautions are not necessary for the client with active tuberculosis. Reverse isolation is not required for the client with active tuberculosis

Your patient starts to shiver uncontrollably after surgery. Which nursing intervention would be your priority? A. Apply warm blankets & continue o2 as prescribed B. Take the pts temperature C. Page the DR for further orders D. Adjust the temperature in the room

ANS: A. Apply warm blankets & continue o2 as prescribed Rationale: Shivering can be an early sign that the patient is starting to experience hypothermia. The priority is to control the shivering by applying warm blankets and continue oxygen. Then the nurse would take the patient's temperature

The nurse receives a telephone call from the post-anesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? A. Assess the patency of the airway. B. Check tubes or drains for patency. C. Check the dressing to assess for bleeding. D. Assess the vital signs to compare with preoperative measurements.

ANS: A. Assess the patency of the airway. Rationale: The first action of the nurse is to assess the patency of the airway and respiratory function. If the airway is not patent, the nurse must take immediate measures for the survival of the client. The nurse then takes vital signs followed by checking the dressing and the tubes or drains. The other nursing actions should be performed after a patent airway has been established.

When caring for a patient with rubella, in addition to standard precautions, which precautions would be used? A. Droplet precautions B. Airborne precautions C. Contact precautions D. Universal precautions

ANS: A. Droplet precautions Rationale: Focus on diseases that are transmitted by large droplets expelled into the air and travel 3 to 6 feet from the patient. Droplet precautions require the wearing of a surgical mask when within 3 feet of the patient, proper hand hygiene, and some dedicated-care equipment. An example is a patient with influenza.

In preventing and controlling the transmission of infections, the single most important technique is: A. Hand hygiene B. The use of disposable gloves C. The use of isolation precautions D. Sterilization of equipment

ANS: A. Hand hygiene Rationale: The most important and most basic technique in preventing and controlling transmission of infections is hand hygiene. Use of disposable gloves may help reduce the transmission of infections but is not the single most important technique to prevent and control the transmission of infections. The use of isolation precautions is not the single most important technique to prevent and control the transmission of infections. Sterilization of equipment is not the single most important technique to prevent and control the transmission of infections.

The nurse is changing linens for a postoperative patient and feels a stick in her hand. A nonactivated safe needle is noted in the linens. This scenario would indicate that the nurse may be at risk for A. Hepatitis B. B. Clostridium difficile. C. Methicillin-resistant Staphylococcus aureus. D. Diphtheria.

ANS: A. Hepatitis B. Rationale: Bloodborne pathogens such as those associated with hepatitis B and C are most commonly transmitted by contaminated needles. Clostridium difficile is spread by contact with and ingestion of this microbe, and MRSA is spread by contact. Diphtheria is spread by droplets when one is within 3 feet of the patient.

The severity of a patient's illness depends on all of the following except: A. Incubation period B. Extent of infection C. Susceptibility of the host D. Pathogenicity of the microorganism

ANS: A. Incubation period Rationale: The incubation period is the interval between the entrance of the pathogen into the body and appearance of the first symptoms

An infection occurs as a result of a cyclical process. The six components of an infection are A. Infectious agent, source of infection, portal of exit, mode of transmission, portal of entry, and susceptible host B. Infectious agent, reservoir, portal of exit, vehicle of movement, portal of entry, and susceptible host C. Infectious agent, reservoir, portal of exit, vehicle of transmission, portal of entry, and unsusceptible host D. Invading agent, reservoir, portal of exit, vehicle of transmission, portal of entry, and susceptible host

ANS: A. Infectious agent, source of infection, portal of exit, mode of transmission, portal of entry, and susceptible host Rationale:

When a patient on respiratory isolation must be transported to another part of the hospital, the nurse: A. Places a mask on the patient before leaving the room B. Obtains health care provider's order to prohibit the patient from being transported C. Instructs the patient to cover his or her mouth and nose with a tissue when coughing or sneezing D. Advises other health team members to wear masks and gowns when coming in contact with the patient

ANS: A. Places a mask on the patient before leaving the room Rationale: Patients who are transported outside of their rooms need to wear surgical masks to protect other patients and personnel

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

ANS: A. Private room Rationale:

The nurse sets up a non-barrier sterile field on the patient's over-bed table. In which of the following instances is the field contaminated? A. Sterile saline solution is spilled on the field B. The nurse, who has a cold, wears a double mask C. Sterile objects are kept within a 1-inch border of the field D. The nurse keeps the top of the table above his or her waist

ANS: A. Sterile saline solution is spilled on the field Rationale: If moisture leaks through a sterile package's protective covering, organisms can travel to the sterile object

You are observing your patient use the incentive spirometry. What demonstration by the patient lets you know the patient understands how to use the device properly? A. The patient inhales slowly on the device and maintains the flow indicator between 600 to 900 level B. The patient blows on the mouthpiece rapidly. C. The patient uses the incentive spirometry once a day D. The patient rapidly inhales on the devices and exhales

ANS: A. The patient inhales slowly on the device and maintains the flow indicator between 600 to 900 level Rationale: All of the options are wrong expect for "The patient inhales slowly on the device and maintains the flow indicator between 600 to 900 level". The other options do not demonstrate how to properly use the incentive spirometry.

Your ungloved hands come in contact with the drainage from your patient's wound. What is the correct method to clean your hands? A. Wash them with soap and water. B. Use an alcohol-based hand cleaner. C. Rinse them and use the alcohol-based hand cleaner. D. Wipe them with a paper towel.

ANS: A. Wash them with soap and water.

The nurse is caring for a postoperative patient at risk for pneumonia. What interventions can be implemented to reduce the risk of pneumonia? Select all that apply. A. Limiting fluids B. Incentive spirometer C. Early ambulation D. Frequent repositioning E. Bed rest F. Coughing

ANS: B, C, D, F Rationale: To prevent the development of pneumonia, the patient should cough, deep breathe, reposition frequently and ambulate early, and use the incentive spirometer. Bed rest and limiting fluids will increase the risk of pneumonia.

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? (Select all that apply). 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 to 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.

ANS: B, C, E Rationale: Wear a mask within 3 ft of the client. Place a surgical mask on the client during transport to another area of facility. Wear a gown if the nurse's clothing or skin might be contaminated with body secretions or excretions

Which of the following assessment data indicate the presence of a local inflammatory process? (Select all that apply.) A. Client reports being cold B. Left elbow warm to the touch C. Elevated white blood cell (WBC) count D. Pitting edema of +2 around the right ankle E. Client reports knee pain of 5 on a scale of 1 to10 F. Client observed grimacing while raising shoulder to brush hair

ANS: B, D, E, F Rationale: Signs of localized inflammation include swelling, redness, heat, pain or tenderness, and loss of function in the affected body part. When inflammation becomes systemic, other signs and symptoms develop, including fever, leukocytosis, malaise, anorexia, nausea, vomiting, lymph node enlargement, or organ failure.

When conducting preoperative patient and family teaching, you demonstrate proper use of the incentive spirometer. You know that the patient understands the need for this intervention when the patient states, "I use this device to: A. Help my cough reflex." B. Expand my lungs after surgery." C. Increase my lung capacity." D. Drain excess fluid from my lungs."

ANS: B. "Expand my lungs after surgery." Rationale: Use of an incentive spirometer promotes expansion of the lungs. The patient should try to reach the inspiratory target volume achieved before surgery on the spirometer. (PowerPoint Q)

The nurse is monitoring the patient who is 24 hours post-opt from surgery. Which finding requires intervention? A. BP 101/79 B. 24-hour urine output of 300 ml C. Pain rating of 4 on 1-10 scale D. Temp of 99.4' F

ANS: B. 24-hour urine output of 300 ml Rationale: The nurse needs to watch the patient's urinary output closely. Urinary output within a 24-hour period should be at least 30 ml/hr. In this case, the patient is only urinating 12.5 ml/hr.

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

ANS: B. 40-year-old who has an indwelling urinary catheter in place Rationale:

When a nurse is performing surgical hand asepsis, the nurse must keep hands: A. Below elbows B. Above elbows C. At a 45-degree angle D. In a comfortable position

ANS: B. Above elbows Rationale:

If an infectious disease can be transmitted directly from one person to another, it is a: A. Susceptible host B. Communicable disease C. Port of entry to a host D. Port of exit from the reservoir.

ANS: B. Communicable disease Rationale: If an infectious disease can be transmitted directly from one person to another, it is termed a communicable disease

As the nurse you are getting the patient ready for surgery. You are completing the preoperative checklist. Which of the following is not part of the preoperative checklist? A. Assess for allergies B. Conducting the Time Out C. Informed consent is signed D. Ensuring that the history and physical examination has been completed

ANS: B. Conducting the Time Out Rationale: The time out is conducted by the OR nurse prior to surgery. All of the other options are conducted by the nurse getting the patient ready for surgery.

A patient's surgical wound has become swollen, red, and tender. You note that the patient has a new fever and leukocytosis. What is the best immediate intervention? A. Notify the health care provider and use surgical technique to change the dressing B. Reassure the patient and recheck the wound later C. Notify the health care provider and support the patient's fluid and nutritional needs D. Alert the patient and caregivers to the presence of an infection to ensure care after discharge

ANS: C. Notify the health care provider and support the patient's fluid and nutritional needs Rationale:

A patient reports he hasn't had a bowel movement or passed gas since surgery. On assessment, you note the abdomen is distended and no bowel sounds are noted in the four quadrants. You notify the MD. What non-invasive nursing interventions can you perform without a MD order? A. Encourage at least 3000 ml of fluids per day B. Encourage ambulation, maintain NPO status, and monitor intake and output C. Insert a nasogastric attached to intermittent suction D. Administer IV fluids

ANS: B. Encourage ambulation, maintain NPO status, and monitor intake and output Rationale: This patient is most likely experiencing a paralytic ileus which is failure for the bowels to move its contents. The only correct non-invasive option is to encourage ambulation, maintain NPO status, and monitor intake & output. Inserting a NG tube or administering IV fluids is invasive and requires a MD order. Patients with potential paralytic ileus are to be NPO (nothing by mouth) so encouraging fluid intake is incorrect.

What is a potential post-op concern regarding a patient who has already resumed a solid diet? A. Failure to pass stool within 12rs of eating solid foods B. Failure to pass stool within 48 hours of eating solid foods C. Excessive flatus is passed D. A decreased appetite

ANS: B. Failure to pass stool within 48 hours of eating solid foods Rationale: After a patient resumes solid food, they should have a bowel movement within 48 hours. The patient may be experiencing constipation and appropriate interventions must be followed.

A patient is now in the recovery room after having vaginal surgery. Due to the positioning of the procedure, you would want to assess for what while the patient is in recovery? A. Hemoglobin Level B. Homan's Sign C. Bowel Sounds D. Dysrhythmia

ANS: B. Homan's Sign Rationale: Vaginal surgeries require the patient to be in the lithotomy position. This position can put the patient at risk for a deep vein thrombosis. Therefore, the nurse would want to check for this by using Homan's Sign.

The nurse is caring for a patient who has a bloodborne pathogen. The nurse splashes blood above the glove to intact skin while discontinuing an intravenous infusion. The nurse's best next step is to A. Obtain an alcohol swab, remove the blood with an alcohol swab, and continue care. B. Immediately wash the site with soap and running water and seek guidance from the manager. C. Delay washing of the site until the nurse is finished providing care to the patient. D. Do nothing; accidentally getting splashed with blood happens frequently and is part of the job.

ANS: B. Immediately wash the site with soap and running water and seek guidance from the manager. Rationale: After getting splashed with blood from a patient who has a known bloodborne pathogen, it is important to cleanse the site immediately and thoroughly with soap and running water and notify the manager and employee health for guidance on next steps in the process. Removing the blood with an alcohol swab, delaying washing, and doing nothing because the splash was to intact skin could possibly spread the blood within the room and could spread the infection. Contain contamination immediately to prevent contact spread.

You are caring for a patient who underwent surgery 48 hours ago. On physical assessment, you notice that the wound looks red and swollen. The patient's WBCs are elevated. You should: A. Start antibiotics B. Notify the provider C. Document the findings and reassess in 2 hours D. Place the patient on isolation precautions

ANS: B. Notify the provider Rationale: When a patient shows signs of infection, the nurse should notify the provider immediately to ensure immediate treatment is given, possibly preventing a systemic infection. (PowerPoint Q)

A patient is 6 days post-opt from abdominal surgery. The patient is to be discharged later today. The patient uses the call light and asks you to come to his room and look at his surgical site. On arrival, you see that approximately 2 inches of internal organs are protruding through the incision. What intervention would you NOT do? A. Cover the wound with sterile normal saline dressing B. Put the patient in prone position with knees extended to put pressure on the site C. Monitor for signs of shock D. Notify the MD and administer as prescribed antiemetic to prevent vomiting

ANS: B. Put the patient in prone position with knees extended to put pressure on the site Rationale: The patient is experiencing wound evisceration. This is an emergent situation. The patient should be placed in low Fowler's position with the knees bent to prevent abdominal tension.

You are making a home visit to a family of 5 children. The youngest, aged 5, has a temperature of 101.1°F, is lethargic, and has a poor appetite. This assessment leads you to the diagnosis of influenza. Based on your knowledge that influenza is an airborne communicable disease, all of the following patient teachings regarding infection are appropriate for the mother and family except A. Keep children home from day care and school while symptoms are present B. Remind family that they only need to wash their hands if they are visibly dirty C. Do not share tissues, dishes, or personal care items to reduce the risk of transmission D. Encourage the family to receive their annual influenza vaccine

ANS: B. Remind family that they only need to wash their hands if they are visibly dirty Rationale:

You are developing a care plan for a pt who is "at risk for developing pneumonia" post-surgery. Which is NOT an appropriate nursing intervention? A. Encourage patient intake of 3000 ml/day of fluids if not contraindicated B. Repositioning every 3-4 hours C. Encourage patient to use the incentive spirometer device 10 times every 1-2 hours while awake D. Encourage early ambulation and patient to get up to eat meals out of bed

ANS: B. Repositioning every 3-4 hours Rationale: All of these are appropriate for this care plan except "repositioning every 3-4 hours". If the patient is unable to re-position themselves or ambulate, they must be re-positioned every 1 to 2 hours minimally.

A nurse is caring for a postoperative client who reports an inability to void. Which initial action by the nurse is most appropriate? A. Turing on running water B. Inserting a urinary catheter C. Palpating the client's bladder D. Reviewing the client's chart for the time of the last voiding.

ANS: C. Palpating the client's bladder Rationale: The bladder should be palpated for distention. The nurse should also observe for other signs of a full bladder such as restlessness or an elevated blood pressure. The nurse should first determine the underlying reason for the client's inability to void. Turning on running water assumes that the client has a full bladder. A urinary catheter should only be inserted if the client has a full and other measures to initiate voiding have been unsuccessful. Though reviewing the chart for the time of the last voiding may assist in determining the underlying problem, client assessment should be the first action.

The nurse is caring for a patient on Contact Precautions. Which of the following actions would be appropriate to prevent the spread of disease? A. Wear a gown, gloves, face mask, and goggles for interactions with the patient. B. Use a dedicated blood pressure cuff that stays in the room and is used for that patient only. C. Place the patient in a room with negative airflow. D. Transport the patient quickly when going to the radiology department.

ANS: B. Use a dedicated blood pressure cuff that stays in the room and is used for that patient only. Rationale: Contact Precautions are a type of Isolation Precaution used for patients with illness that can be transmitted through direct or indirect contact. A patient is placed on Contact Precautions if a disease is present that can be transmitted through direct or indirect contact. Patients who are on Contact Precautions should have dedicated equipment wherever possible. This would mean, for example, that one blood pressure cuff and one stethoscope would stay in the room with the patient and would be used for that patient only. A gown and gloves may be required for interactions with a patient who is on Contact Precautions. A face mask and goggles are not part of Contact Precautions. A room with negative airflow is needed for patients placed on Airborne Precautions; it is not necessary for a patient on Contact Precautions. When a patient on Contact Precautions needs to be transported, he should wear clean gowns, and wheelchairs or gurneys should be covered with an extra layer of sheets. Anyone who might come in contact with the patient needs to be protected, and equipment must be cleaned with an approved germicide after patient use and before another patient uses the shared equipment.

What is the best method to sterilize a straight urinary catheter and suction tube in the home setting? A. Use an autoclave B. Use boiling water C. Use ethylene oxide gas D. Use chemicals for disinfection.

ANS: B. Use boiling water Rationale:

While preparing to do a sterile dressing change, a nurse accidentally sneezes over the sterile field that is on the over-the-bed table. Which of the following principles of surgical asepsis, if any, has the nurse violated? A. When a sterile field comes in contact with a wet surface, the sterile field is contaminated by capillary action B. Fluid flows in the direction of gravity C. A sterile field becomes contaminated by prolonged exposure to air D. None of the principles were violated

ANS: C. A sterile field becomes contaminated by prolonged exposure to air Rationale:

You are completing the history on a patient who is scheduled to have surgery. What health history increases the risk for surgery for the patient? A. Urinary Tract infections B. History of Premature Ventricle Beats C. Abuse of street drugs D. Hyperthyroidism

ANS: C. Abuse of street drugs Rationale: If a patient has a history of street drug abuse this puts them at risk in surgery. This information is very important for the anesthesiologist due to the complications that can arise from the anesthesia. All of the other options are important to note but not a risk for surgery.

When assessing your patient who is post-opt, you notice that the patient's right calf vein feels hard, cord-like, and is tender to the touch. The patient reports it is aching and painful. What would be an inappropriate nursing intervention for this patient? A. Administer anticoagulants as ordered by MD B. Instruct the patient to not sit in one position for a long period of time C. Allow the patient to dangle the legs to help increase circulation and alleviate pain D. Elevate the extremity 30 degrees without allowing any pressure on affected area

ANS: C. Allow the patient to dangle the legs to help increase circulation and alleviate pain Rationale: All options are correct expect for: Allow the patient to dangle the legs to help increase circulation and alleviate pain. The patient should NOT dangle the legs because this causes blood to pool in the lower extremities which will put the patient at risk for another blood clot formation.

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

ANS: C. Contact precautions Rationale: Used for direct and indirect contact with patients and their environment. Direct contact refers to the care and handling of contaminated body fluids. An example includes blood or other body fluids from an infected patient that enter the health care worker's body through direct contact with compromised skin or mucous membranes. Indirect contact involves the transfer of an infectious agent through a contaminated intermediate object such as contaminated instruments or hands of health care workers. The health care worker may transmit microorganisms from one patient site to another if hand hygiene is not performed between patients

A patient is isolated for pulmonary tuberculosis. The nurse notes that the patient seems to be angry, but he knows that this is a normal response to isolation. Which is the best intervention? A. Provide a dark, quiet room to calm the patient B. Reduce the level of precautions to keep the patient from becoming angry C. Explain the reasons for isolation procedures and provide meaningful stimulation D. Limit family and other caregiver visits to reduce the risk of spreading the infection.

ANS: C. Explain the reasons for isolation procedures and provide meaningful stimulation Rationale:

A patient is admitted to a medical unit for a home-acquired pressure ulcer. The patient has Alzheimer's disease and has been incontinent of urine. The nurse inserts a Foley catheter. You will identify a link in the infection chain as: A. Restraints B. Poor hygiene C. Foley catheter bag D. Improper positioning.

ANS: C. Foley catheter bag Rationale: The foley catheter bag could be both a portal of exit and a portal of entry (PowerPoint Q)

Which of the following is not an element in the development or chain of infection? A. Means of transmission B. Infectious agent or pathogen C. Formation of immunoglobulin D. Reservoir for pathogen growth

ANS: C. Formation of immunoglobulin Rationale: Infection occurs in a cycle that depends on the presence of certain elements

What is the proper order of removal of soiled personal protective equipment 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, goggles, gown, mask, and wash hands D. Goggles, mask, gloves, gown, and wash hands

ANS: C. Gloves, goggles, gown, mask, and wash hands Rationale:

A patient has an indwelling urinary catheter. Why does an indwelling urinary catheter present a risk for urinary tract infection? A. It keeps an incontinent patient's skin dry B. It can get caught in the linens or equipment C. It obstructs the normal flushing action of urine flow D. It allows the patient to remain hydrated without having to urinate.

ANS: C. It obstructs the normal flushing action of urine flow Rationale:

The nurse has redressed a patient's wound and now plans to administer a medication to the patient. Which is the correct infection control procedure? A. Leave the gloves on to administer the medication B. Remove gloves and administer the medication C. Remove gloves and perform hand hygiene before administering the medication D. Leave the medication on the bedside table to avoid having to remove gloves before leaving the patient's room.

ANS: C. Remove gloves and perform hand hygiene before administering the medication Rationale:

Your PT is semi-comatose after surgery w/vital signs w/i normal limits. What position would be best for this patient? A. Prone B. Low-Fowlers C. Side positioning preferably on the left side D. Semi-Fowlers

ANS: C. Side positioning preferably on the left side Rationale: A patient who is semi-comatose is at risk for aspiration. Placing the patient onto their side preferably the left will help decrease the risk of aspiration & help promote cardiovascular circulation

Your patient is taking Aspirin 325 mg daily. The patient is scheduled for surgery in a week. What teaching do you provide the patient with before surgery? A. Educate the patient to take the scheduled dose of Aspirin the day of surgery to help prevent blood clots B. To hold his morning dose of Aspirin because the nurse will give it to him before surgery C. The medication should be discontinued for 48 hours prior to the scheduled surgery date D. None of the above

ANS: C. The medication should be discontinued for 48 hours prior to the scheduled surgery date Rationale: Aspirin alters the normal clotting factors and increases the patient's chances of hemorrhaging. Therefore, it should be held for at least 48 hours prior to surgery as specified by the surgeon.

Which of the following is the primary purpose of maintaining NPO for 6 to 8 hours before surgery? A. To prevent malnutrition B. To prevent electrolyte imbalance C. To prevent aspiration pneumonia D. To prevent intestinal obstruction

ANS: C. To prevent aspiration pneumonia Rationale: To prevent aspiration pneumonia. NPO for 6 to 8 hours before surgery prevents vomiting, regurgitation of gastric content. Therefore, this prevents aspiration pneumonia. The primary purpose for maintaining NPO before surgery is to prevent aspiration pneumonia

During normal patient care that does not soil hands, effective hand hygiene between patients requires A. At least a 20-second soap and water scrub. B. At least a 23-minute scrub with antimicrobial soap. C. Use of an alcohol-based antiseptic hand rub D. A mask must be worn while scrubbing is occurring.

ANS: C. Use of an alcohol-based antiseptic hand rub Rationale:

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

ANS: C. Vehicle Rationale:

A client is admitted for treatment of various poorly healing, infected leg ulcers. The nurse recognizes that the client's nutritional history is of primary importance since: A. Nutrition is vital to the client's overall health status B. The client's food intake will likely be decreased as a result of the illness C. Wound healing and infection prevention are negatively impacted by poor nutrition D. The client's habits regarding food intake are directly related to this hospitalization

ANS: C. Wound healing and infection prevention are negatively impacted by poor nutrition Rationale: A reduction in protein, carbohydrates, and fats as a result of illness, inadequate diet, or debility increases a client's susceptibility to infection and delays wound healing. While the other options are not incorrect, they are not as directly related to the cause of the client's poorly healing, infected wounds.

Of the following patients, which patient is at a higher risk of infection? A. 27-year-old female who is an athlete B. 60-year-old male with arthritis C. 12-year-old female with a broken leg D. 36-year-old female with HIV

ANS: D. 36-year-old female with HIV Rationale:

The nurse is educating a client diagnosed with type 2 diabetes, who is susceptible to foot wounds, on how to minimize the risk for infection related to poor wound healing by not being a susceptible host. The most appropriate suggestion would be to: A. Inspect feet and legs daily for skin breakdown B. See a podiatrist regularly for appropriate foot care C. Keep blood sugar levels within normal range to maximize the ability to heal D. Eat well-balanced meals in order to provide the nutrients necessary for healing

ANS: D. Eat well-balanced meals in order to provide the nutrients necessary for healing Rationale: Good infection control begins with prevention. Review with clients and their families' preventive measures to strengthen their defenses. In the case of a diabetic client, keeping blood sugar levels within normal limits maximizes the client's ability to both heal and fight infection. While the other options are not incorrect, they are more directed towards healing than prevention.

A nurse is caring for a client who reports a severe 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

ANS: D. Illness Rationale: The illness stage is when the client experiences manifestations specific to infection

Postoperatively, the nurse instructs the patient to perform leg exercises every hour to: A. Maintain muscle tone. B. Assess range of motion. C. Exercise fatigued muscles. D. Increase venous return.

ANS: D. Increase venous return. Rationale: Postoperative exercises help to prevent pulmonary and vascular complications. Encourage patients to perform leg exercises at least every hour while awake. Exercise may be contraindicated in an extremity with a vascular repair or realignment of fractured bones and torn cartilage. (PowerPoint Q)

Which of the following best describes an iatrogenic infection? A. It results from a diagnostic or therapeutic procedure B. It results from an extended infection of the urinary tract C. It involves an incubation period of 3 to 4 weeks before it can be detected D. It occurs when patients are infected with their own organisms as a result of immunodeficiency

ANS: D. It occurs when patients are infected with their own organisms as a result of immunodeficiency Rationale: An iatrogenic infection occurs when part of the patient's flora becomes altered and an overgrowth results

A 26-year-old client comes into the clinic prior to a tonsillectomy. Which action is priority during this phase of surgery? A. Intraoperative medication B. Intraoperative consent signed C. Postoperative assessment D. Preoperative assessment

ANS: D. Preoperative assessment Rationale: The client is in the preoperative phase of surgery and must be assessed and prepared for surgery. The client may have labs drawn, medication administered, and consent forms signed. The intraoperative phase is the actual surgery; the client is anesthetized, prepped, draped, and surgery performed. The postoperative phase is the recovery phase of surgery where the client continues to recover until maximum health is achieved.

A nurse is caring for an overweight 60-year-old woman with a reddened area over her coccyx. The priority nursing diagnosis for this patient is A. Imbalanced Nutrition: More Than Body Requirements related to immobility B. Impaired Physical Mobility related to pain and discomfort C. Chronic Pain related to overweight D. Risk for Infection related to altered skin integrity

ANS: D. Risk for Infection related to altered skin integrity Rationale:

As a nurse, which statement is incorrect regarding an informed consent signed by a patient? A. The nurse can witness the client signing the consent form B. It is the nurse's responsibility to ensure the patient has been educated by the physician about the procedure before informed consent is obtained C. Patients under 18 years of age may need a parent or legal guardian to sign a consent form D. The nurse is responsible for obtaining the consent for surgery

ANS: D. The nurse is responsible for obtaining the consent for surgery Rationale:

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. Ring worm C. Systemic lupus erythematosus D. Tuberculosis

ANS: D. Tuberculosis Rationale: A cough for 3 weeks and beginning to cough up blood are manifestations of TB

A 51-year-old patient is admitted to a medical-surgical unit with a systemic infection. The nurse would expect to see which of the following signs and symptoms in this patient? A. redness, fever, edema B. drainage, nausea, fever C. edema, malaise, and fever D. fever, fatigue, nausea

ANS: D. fever, fatigue, nausea Rationale:

You are caring for a patient who underwent sterile 48 hours ago. On physical assessment, you notice that the wound looks red and swollen. The patient's WBCs are elevated. You should: a. start antibiotics b. notify the provider c. to document the findings and reassess in 2 hours d. place the patient on isolation precautions

B. Notify the provider

Donning and Doffing PPE

DONNING gown, mask, goggles gloves DOFFING Gloves, goggles, gown mask

Preoperative medications:

Gabapentin Tylenol - acetaminophen Oxytocin

A nurse may give preoperative pain medications which are called what? What are types of pain meds that may be given?

Multimodal medications consist of different pain meds with different pathways such as gabapentin, acetaminophen (Tylenol), OxyContin

Two patient identifiers are:

Name and DOB

Once you have sterilized your hands you should keep your hands and objects:

No where below the waist

What if a patient does not think that they need surgery, or does not understand the procedure?

Notify the surgeon

Would sites:

Start locally and then become systemic

Who is responsible for making surgery sites?

Surgeons

What vitamin may we use to support patients with risk of infection?

Vitamin C

What is the best way to prevent infection risk?

WASH YOUR HANDS

When should you wear gloves?

When in contact with any bodily fluid

Pressure injury prevention in surgery patients begins:

during surgery

Infection Process

the incubation period, symptoms, proliferation, containment, resolution