Jared Griffin V Sim
Pre-Stimulation Quiz Q1: Which intervention(s) will the nurse implement when maintaining medical asepsis?
Clean the least soiled areas first. Practice good hand hygiene. Do not place soiled bed linen on the floor. Keep personal fingernails short.
Pre-Stimulation Quiz Q6: Which intervention(s) will help minimize the risk of infection postoperatively?
Following aseptic technique when changing incision dressings Implementing standard precautions Assessing temperature frequently Maintaining hydration
Pre-Stimulation Quiz Q9:When bathing a patient who requires contact and droplet precautions, which personal protective equipment (PPE) will the nurse put on?
Gloves Mask
Jared Griffin - Background
Mr. Griffin has been placed on contact precautions because he is a carrier of MRSA. This was diagnosed 3 years ago when he had surgery for a hammertoe. A nasal swab was done in the office during his recent preoperative check that came back positive for MRSA. Decolonization protocol was initiated prior to the admission for the total knee procedure, and he is currently under contact precautions per hospital policy. He has a history of osteoarthritis and mild hypertension
Pre-Stimulation Quiz Q4: The nurse is caring for a patient who has been diagnosed with an infection. The nurse identifies which of the following stages of infection as posing the greatest risk to others?
Prodromal
Post-Stimulation Quiz Q5: The nurse is completing a postarthroplasty focused assessment on Mr. Griffin to determine musculoskeletal and neurovascular status. Which of the following would be included in this assessment?
Skin color Skin temperature Capillary refill Pedal pulses Toe movement Range of motion Muscle strength
Pre-Stimulation Quiz Q8: The nurse is conducting a neurovascular assessment on a postoperative patient who experienced a total knee arthroplasty (TKA). What initial intervention(s) should be performed by the nurse when it appears that there is an absence of a pulse in the affected foot?
Elevate the affected extremity. Assess for paresthesia in the affected extremity. Notify the patient's health care provider of the assessment finding. Assess the capillary refill and skin color in both lower extremities. Assess the peripheral pulses in both lower extremities.
Jared Griffin - Recommendation
I would like you to perform Mr. Griffin's morning assessment, paying special attention to his neurovascular status. Continue with contact precautions and observe for any signs and symptoms of infection.
Post-Stimulation Quiz Q3: The nurse caring for Mr. Griffin understands which of the following nursing interventions will have the greatest impact on minimizing the spread of methicillin-resistant Staphylococcus aureus (MRSA) to other clients on a surgical unit?
Instituting meticulous handwashing technique, Implementing contact precautions, Using appropriate personal protective equipment (PPE)
Pre-Stimulation Quiz Q3: When considering a 40-year-old postoperative patient, which factor is likely to present the greatest risk for the development of an infection?
Invasive or indwelling medical procedures or devices
Jared Griffin - Situation
Jared Griffin is a 63-year-old male who had a right total knee arthroplasty yesterday morning.
Jared Griffin - Assessment
Mr. Griffin is afebrile with a temp of 98.9 °F (37.2 °C), and vital signs have been stable during the night. Patient reported pain at site of incision, 6/10. Ibuprofen given orally at 0600. He has dangled his feet off the side of the bed and will have physical therapy in his room at 1000. He has been able to bend his knee to a 75-degree angle, and the goal is 90 degrees. The surgeon changed Mr. Griffin's dressing and discontinued his drain and IV fluids, at 0700 this morning. The a.m. lab results are complete, but I haven't had a chance to review them yet.
Post-Stimulation Quiz Q4: The nurse caring for Mr. Griffin identifies which of the following as priority nursing actions when caring for a client under contact precautions?
Performing hand hygiene Putting on gown Donning gloves Isolating client care equipment
Post-Stimulation Quiz Q6: The nurse provides client education regarding range of motion exercises to Mr. Griffin in preparation for his pending discharge home. The nurse recognizes that Mr. Griffin understands the information provided when he states which of the following?
Range of motion exercises should be performed slowly and gently. I should perform range of motion exercises on both sides. It may be necessary to continue physical therapy after going home. I will need to use a walker or crutches after discharge.
Pre-Stimulation Quiz Q7: The nurse is providing training to the staff in a hospital setting regarding the prevention of health care associated infections (HAIs). The nurse identifies which of the following categories as being responsible for the majority of HAIs in the acute care hospital setting?
Ventilator associated pneumonia Central line associated bloodstream infection Surgical site infection Catheter associated urinary tract infection
Post-Stimulation Quiz Q2: Mr. Griffin's diagnostic results and recognizes which findings should be reported to the health care provider immediately?
WBC 19,000/µL Hb 8.5 g/dL
Pre-Stimulation Quiz Q2: The nurse is caring for a patient the day after invasive surgery. The nurse is aware that review of which of the following should be included when assessing for the presence of a systemic infection?
White blood cell count Body temperature
Post-Stimulation Quiz Q1: The nurse caring for Mr. Griffin is assessing for signs and symptoms of infection and recognizes the importance of including which of the following as part of the assessment?
White blood cell count Temperature Pain level Surgical site assessment
Pre-Stimulation Quiz Q5: The nurse is conducting a neurovascular assessment on a postoperative knee replacement patient. Which assessment data could be considered an initial indication of neurological impairment?
Patient reports "pins and needles" sensation below the incision site.