NUR215 Exam 1 Elsevier
When should an attempt to fight fire be made in hospital?
only when fire is contained to a small area
protective environment precautions
positive airflow set to > 12 air exchanges HEPA filter
Examples of passive strategies aimed at health promotion
public health and government legislative interventions
Scabies spread via
skin contact
What is included under surgical events?
surgeries performed on the wrong body part wrong surgical procedure
Antibiotics in women can cause
yeast injections
restraint orders ages 9 and below
1 hour
EAQ Chapter 28 #15 Place the chain of infection in the correct order
1) Infectious agent 2) Reservoir 3) Portal of exit 4) Mode of transmission 5) Portal of entry 6) Susceptible host
EAQ Chapter 28 #17 What are the stages on infection in order?
1) Invasion of the pathogen into body 2) Incubation period (interval between entrance of pathogens and first symptoms, 3) Prodromal stage (nonspecific signs and symptoms like fatigue) 4) Illness stage (pt manifests signs and symptoms specific to infection) 5) Convalescence (acute symptoms of infection disappear)
EAQ Chapter 28 #16 Arrange the steps for applying PPE in the correct order
1) Perform hand hygiene 2) Put on gown 3) Put on mask 4) Put on eyewear 5) Put on gloves
EAQ Chapter 28 #14 When the nurse leaves an isolation room, arrange the steps of PPE removal in order
1) Remove gloves 2) Remove eyewear 3) Remove gown 4) Remove mask 5) Preform hand hygiene
What routine home treatment actions for posioning should be taken?
1) position head turned to side to prevent choking 2) Assess for signs of symptoms (vomiting, nausea, foaming) 3) Identify type and amount *do not administer ipecac syrup: indudes vomiting
restraint order for ages 9-17
2 hours
Quiz 1 #18 Fall risk preventions include which of the following A) Elimination schedules B) Raising all side rails C) Reviewing meds D) Non-slip socks E) Assistive for walking
A C D E
EAQ Chapter 27 #9 Information to consider when discharging older patients at risk for falls? A) A safe environment promotes patient activity B) Assessment focuses on environmental factors only C) Teaching home safety in the hospital is difficult D) Most accidents with the older adult are caused by lifestyle factors
A) A safe environment promotes patient activity Rationale B) assessment focuses on more than just environmental factors C) teaching home safety can be easily done in hospital D) Most accidents with older adults are caused by home hazards
EAQ Chapter 27 #5 The nurse notes a patient has a diagnosis of risk for falling owing to left-sided weakness which impaired their gait. What intervention should nurse anticipate? A) Explain the fall risks associated with the patient's stroke B) Explain the potential effects of medications on their balance C) Implement endurance training after patient is competent in using a walker D) Teach the patient strengthening exercises in collaboration with physical therapy
A) Explain the fall risks associated with the patient's stroke Rationale B health seeking behavior C and D are for mobility
EAQ Chapter 28 #24 A systemic infection causes which symptom(s)? A) Fatigue B) Redness C) Swelling D) Warmth E) Malaise
A) Fatigue E) Malaise Rationale -Systemic infection= fatigue, malaise, fever, and vomiting, anorexia -Localized infection= redness, swelling, warmth
EAQ Chapter 28 #12 To reduce the transmission of disease, which step would the nurse take when administering medication to a patient with Clostridium difficile infection? A) Give oral meds using a disposable cup B) Wash hands with antimicrobial soap and water C) Wear a respirator mask D) Discard safety needles into sharps container E) Wear gloves when administering an injection
A) Give oral meds using a disposable cup B) Wash hands with antimicrobial soap and water D) Discard safety needles into sharps container E) Wear gloves when administering an injection
Quiz 1 #14 MOST concern for risk of falls A) Has a history of falls B) Uses a cane (ambulation) C) Takes blood pressure meds D) Has a urinary catheter
A) Has a history of falls Rationale B) ambulation= walking, so still true, just not most C) dizzy spells, so still true D) trip and fall, so still true
Which care intervention would reduce the risk of sudden infant death syndrome (SDS)? A) Immunizing the infant B) Following proper protocol for storing food C) Using large, soft toys D) Avoiding leaving the baby unattended on the changing table
A) Immunizing the infant
EAQ Chapter 27 #2 A patient has consumed kerosene. What intervention would further complicate this pt's condition? A) Inducing vomiting B) Maintaining the airway C) Administering oxygen D) Measuring oxygen saturation
A) Inducing vomiting Rationale **inducing vomiting can cause aspiration **oxygen administration is helpful in kerosene poisoning
EAQ Chapter 28 #2 The nurse expects which additional assessment finding in a patient who is 10 days post-hysterectomy who reports purulent drainage at the incision site? A) Pain B) Redness C) Paleness D) Tenderness E) Coolness
A) Pain B) Redness D) Tenderness
EAQ Chapter 28 #11 During assessment, the nurse notes a break in the skin due to the patient's abscess and identifies that this finding represents which element of the chain of infection? A) Portal of exit B) Reservoir C) Susceptible host D) Infectious agent
A) Portal of exit Rationale A) skin is considered a portal of exit because any break in the skin can allow pathogens (like pus) to exit the body **organisms exit from wounds, venipuncture sites, hematemesis, and bloody stool B) Reservoir is a place inside the body or environment where pathogens can grow C) a susceptible host is someone who is at risk of an infection D) infectious agents are microorganisms that include bacteria, viruses, fungi, and protozoans
EAQ Chapter 28 #23 Which equipment is required for the preparation of a sterile field? A) Sterile drape B) Paper face mask C) Countertop surface D) Protective eyewear E) Surgical scrub (with sponge)
A) Sterile drape C) Countertop surface Rationale B, D, E are required for sterile asepsis
Which type of specimen is collected by using a sterile tongue blade? A) Stool B) Urine C) Blood D) Wound
A) Stool Rationale **urine taken by urinary catheter **blood collected with 20-mL-needle-safe syringes **wound with sterile cotton-tibbed swabs or syringes
EAQ Chapter 27 #11 A RN is teaching older adults about safety measures related to the physiological changes associated with aging. Which statement indicates the need for further teaching? A) Take diuretics in the evening B) Restrict driving to daylight hours C) Seek assistance from others with household tasks D) Use medication organizers and fill them once a week E) Perform vision and hearing exams every 2 years
A) Take diuretics in the evening E) Perform vision and hearing exams every 2 years Rationale A) diuretics should be taken in the AM E) exams annually
EAQ Chapter 28 #7 Which statement is true regarding the infant immune system? A) The immune system matures as the child grows. B) The infant has refined defenses against infection. C) The immunity of a bottle-fed infant is usually greater than breastfed infants. D) The infant immune system is capable of producing necessary immunoglobulins.
A) The immune system matures as the child grows.
EAQ Chapter 28 #8 Which statement regarding inflammation as a response to cellular injury is true? A) Vasodilation occurs at the site of injury B) Chronic inflammation is an immediate response to cellular injury C) Increased blood flow leads to coolness at site of inflammation D) The cellular response involved red blood cells at the site of infection
A) Vasodilation occurs at the site of injury Rationale A) Rapid vasodilation promotes more blood to be delivered to site of injury B) The immediate response is acute, not chronic C) The increased blood flow causes redness and localized warmth D) The cellular response includes white blood cells
EAQ Chapter 28 #19 A parasitic condition caused by a tick is an example of which mode of transmission? A) Vector B) Vehicle C) Airborne D) Direct contact
A) Vector Rationale STUDY BOX 28.1 A) vectors include mosquitoes, lice, ticks, fleas B) Vehicle include contaminated items such as food, water, drugs, solutions, blood C) Airborne is droplets in air D) physical contact
Quiz 1 #3 Inflammation can shift to infection rapidly. What indicates this? A) Yellow discharge B) Swelling around site C) Inability to flex finger D) Feeling of heat when touched
A) Yellow discharge
The spaces between crib slats should be less than how many centimeters apart? A) 6cm B) 10cm
A) less than 6cm Rationale **So that the child's head cannot get wedged between them, causing asphyxiation
EAQ Chapter 27 #7 Which reason(s) would justify the use of restraints on a disoriented patient? A) Helps reduce the risk of patient injury from falls B) Prevents the patient from removing IV C) Helps control the patient D) Helps reduce the risk of injury to others by the patient E) Minimizes the need for supervision of patient
A, B, D Rationale **restraints are not used to control or minimize supervision
EAQ Chapter 27 #10 Which factors contribute to overall fall risk? A) Age B) Fall history C) Gender D) Weight E) Medications
A, B, E
Where to keep the hands during a surgical hand scrub?
Above the elbows
Red Wristbands
Allergies
EAQ Chapter 27 #8 Which factor(s) contributes to an increase in falls in older patients? A) Safety devices B) Anticonvulsants C) High bed positioning D) Moderate lighting E) Secure rugs and carpeting
B and C Rationale **Drugs such as anticonvulsants, antidiuretics, and sedatives increase risk of falls
EAQ Chapter 28 #5 Human immunodeficiency virus (HIV) is transmitted via which major reservoir? A) Feces B) Blood C) Semen D) Mouth legions E) Vaginal secretions
B) Blood C) Semen E) Vaginal secretions Rationale A) Major reservoir of Hep A is feces D) Major reservoir of herpes simplex virus type 1 is mouth lesions
Which infection control practice would the nurse implement for a patient who is hospitalized for treatment of an infection with a multidrug-resistant organism? A) Use of N95 B) Contact precautions C) High-efficiency particulate air (HEPA) filter D) Droplet precautions
B) Contact Precautions
EAQ Chapter 27 #6 Which question would be appropriate for the nurse to ask when assessing home maintenance and safety for a patient? A) Have you ever suffered an injury from a fall? B) Do you have someone to call in case of an emergency? C) Has your provider reviewed your medications? D) Do you drive an automobile? When do you normally drive? How far?
B) Do you have someone to call in case of an emergency?
EAQ Chapter 28 #22 Which nursing action may contaminate the surface of a sterile item? A) Disposing of the outer wrapper B) Holding the arm over the sterile field C) Peeling the wrapper onto the non dominant hand C) Allowing the drape to unfold on a surface above waist level
B) Holding the arm over the sterile field
EAQ Chapter 28 #6 The nurse recognizes the importance of preventing which specific type of infection when assisting with a bronchoscope? A) Localized B) Iatrogenic C) Endogenous D) Suprainfection
B) Iatrogenic Rationale A) Localized infection occurs around site of wound B) Endogenous infection often happens when a patient received broad-spectrum antibiotics that affect the normal flora C) Suprainfection develops when broad-spectrum antibiotics kills a wide range of normal flora
Quiz 1 #6 Droplet isolation. Pt is forcefully coughing up green phlegm. What PPE will nurse remove after leaving class? A) Gown and gloves B) Mask with a face shield and gloves C) Mask and gloves D) N95 respirator, gown, and gloves
B) Mask with face shield and gloves Rationale **think of hierarchy -CONTACT= gown and gloves -DROPLET= mask and gloves (within 3ft away) (if forceful coughing)= mask, face shield, and gloves --AIRBORNE= N95 respirator, gloves (smaller droplets) PROTECTIVE CAUTION= gloves and mask (protecting patient)
EAQ Chapter 28 #25 Which equipment is required for surgical hand asepsis? A) Sterile gloves B) Paper face mask C) Protective eyewear D) Clean countertop space E) Surgical scrub (with sponge)
B) Paper face mask C) Protective eyewear E) Surgical scrub (with sponge) Rationale -Surgical hand asepsis= paper face mask, protective eyewear, surgical hand scrub (with sponge) -Prep. Sterile field= sterile gloves and a countertop surface
Quiz 1 #2 The body has a natural defense mechanism against infection. Which of the following suggests a primary defense is impaired? A) Oral mucous membranes are pink B) Skin is dry and cracked C) Eyes appear moist D) Hair seen in nostrils
B) Skin is dry and cracked
Quiz 1 #13 Order for wrist restraint A) Tie the tails of wrist restraints to the side rail B) Tie the tails of wrist restraints to the bed frame C) Provide skin care every 4 hours D) Raise all the side rails
B) Tie the tails of wrist restraints to the bed frame BEFORE RESTRAINTS (last resort) -need an order -try all distractions -Provide skincare every 4 hours -All side rails are considered a restraint; need 3 up regardless; -an exit -2 finger check; mobility and pulse -"quick release" tie
EAQ Chapter 27 #13 Which patient would need a temporary restraint? A) Alert pt B) Confused pt C) Accommodating pt D) Pt who repeatedly falls E) Pt who try to remove medical devices
B, D, E
What is C. diff (Clostridium difficile)
Bacteria In gut can be HAI Contact precautions Smelly, watery diarrhea Spores (wash hands with soap and water) natural flora helps protect, so antibiotics can kill too much of it
Quiz 1 #7 A nurse assesses patients for HAI. What pt is most at risk? A) A 60-year old patient who smokes 2 packs a day B) A 40-year old patient who was a WBC of 6000 (5000-10000) C) A 75-year old patient who has a urinary catheter in place D) A 60-year old patient who is a vegetarian and slightly underweight
C) A 75-year old patient who has a urinary catheter in place RISK FACTORS for HAI -hand hygiene -age (very old and young) -nutrition -invasive procedures (IV, catheter) -how many healthcare workers -how long their stay is -have to be in hospital
Quiz 1 #10 Which child is greatest risk of choking and suffering? A) A toddler playing with basketball B) A 4 year old eating yogurt C) An infant covered with a small blanket and asleep in crib D) A 3 year old drinking a glass of juice
C) An infant covered with a small blanket and asleep in crib PRESCHOOL RISK -injuries at home SCHOOL AGE RISK -to and from -bikes -outdoor play TEENAGE RISK -drugs and alcohol MIDDLE RISK -lifestyle OLDER RISK -falls
Quiz 1 #1 Which clinical manifestation indicates a localized inflammatory response? A) Wound is greenish in color B) Body temp is 101.4 C) Area around the wound is swollen D) Heart rate is 102 beats/min
C) Area around the wound is swollen -tender; heat; localized; immobile Rationale **green and temp indicate a systemic (or infection) **HR would also go up
EAQ Chapter 27 #12 The nurse instructs the parents of an infant not to leave the mesh sides of a playpen lowered to prevent which accidental trauma? A) Falls B) Choking C) Asphyxiation D) Strangulation
C) Asphyxiation
EAQ Chapter 28 #3 Which organism is normal flora of the human colon that can cause infection when it is displaced into the bloodstream? A) Escherichia Colli B) Candida albicans C) Bacteroides fragilis D) Plasmodium falciparum
C) Bacteroides fragilis Rationale A) E.Colli causes gastroenteritis in the colon B) C. Albicans causes candidiasis, pneumonia, and sepsis D) P. Falciparum causes malaria
EAQ Chapter 28 #20 Which factor can alter the infection defense mechanism of sebum? A) Abrasions B) Dehydration C) Excessive bathing D) Improper hand washing technique
C) Excessive bathing Rationale STUDY BOX 28.2 A) abrasions provide an entrance for microbial infection in skin B) dehydration cause cause infection in oral cavity D) improper hand washing can cause infection various ways (contact, and vehicle)
EAQ Chapter 28 #1 What source is an example of the vehicle mode of transmission for infection? A) Mosquitoes B) Flies C) Intravenous (fluid) D) Water E) Food
C) Intravenous (fluid) D) Water E) Food Rationale **Box 28.1 is helpful A) Mosquitoes are vector form of transmission
EAQ Chapter 27 #4 The RN is teaching about safety for equipment-related accidents. Which statement by the nursing student indicates the need for further learning> A) Free flow protection devices should be used B) Place a tag on faulty equipment C) Make regular safety check of equipments D) Do not operate the equipment without instructions
C) Make regular safety check of equipments Rationale **safety checks are completed by clinical engineering staff NOT nurse
EAQ Chapter 28 #9 Which Major reservoir hosts the microbe that causes gas gangrene? A) Water B) Oxygen C) Organic matter D) Undigested food in the bowel
C) Organic matter Clostridium perfringens causes gas gangrene and thrives most only organic matter Rationale A) spores live on water B) staphylococcus aureus require oxygen for survival/ cause disease D) E. Colli consumes undigested food in the bowel
EAQ Chapter 27 #1 Oxygen tanks in a hospital. Which statement made by a student nurse indicates a need for further teaching? A) Check the oxygen tank's tubing for kinks. B) Post No Smoking signs C) Place the oxygen tanks in an upright position on the floor when not in use D) Take the health care provider's advice while changing the lite flow of oxygen
C) Place the oxygen tanks in an upright position on the floor when not in use Rationale **Oxygen tanks need to be stored in an upright position in stands NOT on floor
A patient reports difficulty seeing objects at a distance after a cerebrovascular accident. Which result would the nurse anticipate? A) Risk of falls B) Anxiety related to fear of falling C) Unilateral neglect resulting from brain injury D) Impaired physical mobility on one side of the body
C) Unilateral neglect resulting from brain injury
EAQ Chapter 28 #13 After caring for a patient with diarrhea, which procedure would the nurse employ to clean visibly soiled hands? A) Wash with water B) Clean with waterless hand sanitizer C) Wash with soap and water D) Clean with an alcohol-based product
C) Wash with soap and water Rationale If the hands are not visible soiled, it would be appropriate to use waterless hand sanitizer or an alcohol-based product
What is the best resource for poison victims?
Call the poison control center
Quiz 1 #5 What to wear for standard precaution(s)
Gloves (when contact with body fluid) Goggles (if risk for splash)
Anethesia equipment Endoscopes Endotracheal tubes require...
HLD or sterilization
What is included under patient-protection events?
Infant discharge to unauthorized person Patient committing suicide
Quiz 1 #15 Most important before leaving bedside "If you could do one thing for patient safety?"
Lower the bed to lowest position
Quiz 1 #11 Fire priority?
RACE Code Red= fire Rescue Activate alarm Contain fire Extinguish
What is the mnemonic RACE and when is it used?
Rescue (patients in immediate danger) Activate (alarm) Confine (fire by closing all doors, windows, turning off electric) Extinguish Used during fire emergencies
Quiz 1 #20 Natural defenses organs/systems
Respiratory Vagina Mouth Eye SKin **No GI tract
EAQ Chapter 28 #4 Signs of localized inflammation include?
Swelling, redness, heat, pain or tenderness, and loss of function in the affected body part
True or false: children should not used electrical equipment?
True (Table 27.2)
Quiz 1 #17 Most important thing to stop spread of infection
Wash hands
Contact precaution requires
a gown and gloves **because the handling of contaminated body fluids may cause infections
Droplet precautions require
a surgical mask within 3 feet of pt
What is included under criminal events?
abduction of a patient sexual assault in the hospital setting
Chickenpox (Varicella) spreads via
airborne
Measles spread via
airborne
Study Tip: What absolute terms usually indicate an incorrect answer?
always, never, all, and only
Example of a chemical restraint
anxiolytics or sedatives
Urinary catheters Surgical instruments require...
critical items sterile
What is included under care-management events?
disability associated with a medical error death caused by medication error
Diphtheria spreads via
droplet
Influenza spreads via
droplet
Pertussis spreads via
droplet
TJC 2021 National Patient Safety Goals
identifying patients correctly and using correct patient identifiers
restraint order for adults
limited to 8hrs
Airborne precautions require
negative airflow ("airborne infection isolation room")
Stethoscopes require...
noncritical disinfection of surface
Purple wristbands
DNR
Quiz 1 #9 Confused patient accidently touches sterile field. What is appropriate nursing action?
Discard the supplies and prepare a new sterile field with another person holding the patient's hand
Quiz 1 #19 Factors influencing infection prevention and control
Disease process Stress Nutritional status Age
Quiz 1 #16 Leading cause of physical injury for adolescence
Drugs and alcohol
Yellow wristbands
Fall risk
EAQ Chapter 27 #14 Which nursing activity is performed during safety planning for a patient? A) Identify the pt's perception of safety needs and risks B) determine the effect of the underlying illness on pt safety C) Determine the effect of environmental influence on pt safety D) consult with occupational and physical therapists for assistive devices E) select interventions that will improve safety of patient's home environment
D) E) Rationale Assessing patient's safety= A, B, C During the safety planning phase= D and E
Quiz 1 #8 A procedure that required surgical asepsis, the nurse must: A) Keep splashes on sterile field to a minimum B) Cover the nose and mouth with gloves hands if sneezing C) Use forceps soaked in water D) Consider the outer 1 inch of the sterile field as contaminated
D) Consider the outer 1 inch of the sterile field as contaminated PRINCIPLES OF SURGICAL ASEPSIS -sterile to sterile -don't turn your back on the sterile field -keep within the range (above waist, below head) -when opening sterile gloves, only can touch 1 inch border -longer exposure to air, longer risk for growth or organisms
Quiz 1 #12 Priority for older patients for safety in room A) Explain how to use the telephone B) Introduce the patient to her roommate C) Review hospital hours D) How to operate call light
D) How to operate call light
EAQ Chapter 28 #10 Which PPE is most important to wear when entering a room with pt that has Myobacterium tuberculosis infection? A) Gown B) Gloves C) Head cap D) N95 respirator
D) N95 respirator Rationale A) contact precaution B) contact precaution C) typically worn during surgery D) airborne precaution
which nursing activity is involved in evaluation to determine patient safety? A) Identifying the patient's perceptions of safety needs and risks. B) Identifying the actual and potential threats to the patient's safety. C) Determining the effect of the underlying illness on the patient's safety. D) Reassessing the patient for the presence of physical, social, and environmental risks.
D) Reassessing the patient for the presence of physical, social, and environmental risks. Rationale **The nurse reassesses during evaluation **During assessment, the nurse is identifying actual and potential threats and determining the effect of the underlying illness on patient's safety
Which statement is true regarding the use of patient restraints? A) restraints are ordered prn B) the use of restraints involves a psychological adjustment for the family C) informed consent from family members is required before using restraints D) restraints are part of the patient's prescribed medical treatment and plan of care
D) restraints are part of the patient's prescribed medical treatment and plan of care Rationale **restraints are not ordered prn **informed consent is not needed in acute, but long-term settings
