Concepts of safety and asepis

The nurse is caring for a 35-year-old patient who sustained a penetrating abdominal wound and multiple bruises and contusions in a farming accident. The abdominal wound was very contaminated, but cleaned before and during surgery. The wound-care specialist has been consulted and has taught the nursing staff how to do the dressing changes. The patient has a peripheral IV and is receiving IV antibiotics and pain medication. The nurse identifies that the patient is at risk for infection. a. Give examples of questions that the nurse could use to collect data about factors that would affect the patient's immunologic defense mechanisms.

"What is your typical breakfast, lunch, and dinner?" (To determine nutritional status and eating preferences) "Do you have any health problems? Does your immediate family have any health problems? " (Disease or hereditary factors) "Are you currently taking any kinds of prescribed, over-the-counter, or illicit drugs? " (Some medications alter immune response.) "Have you recently had chemotherapy or radiation therapy? " (Chemotherapy and radiation lower immune response.) "Do you smoke or use alcohol? If so, how much and how frequently? " (Excessive use of tobacco and/or alcohol contributes to chronic illness. Both can alter immune response and healing.) "Do you practice healthy habits, such as exercise?" (Better baseline health contributes to the immune response.) "What do you do for work?" (Occupational exposure to toxins, stress, or pathogens affects immune status.) "Are you currently experiencing stress at work, home, or otherwise?" (Stress adversely affects immune response.)

Identify how a patient that has inflammation of the perianal tissue might be affected or altered by bathing

A sitz bath is indicated.

Which actions require intervention? Select all that apply. A) A nursing student uses hot water to clean fecal material from a bedpan. B) A new nurse uses a mask, protective eyewear, fluid-resistant gown, and gloves when handling a bedpan. C) A UAP dons gloves before performing perineal care. D) An HCP puts a blood-encrusted instrument into the patient's sink. E) A nurse uses a small brush and applies friction to remove dried blood in the grooves of an instrument.

A) A nursing student uses hot water to clean fecal material from a bedpan. B) A new nurse uses a mask, protective eyewear, fluid-resistant gown, and gloves when handling a bedpan. D) An HCP puts a blood-encrusted instrument into the patient's sink.

A neighbor tells the nurse that he has muscle soreness and stiffness after performing a new exercise program. What would the nurse recommend?

A) A tub bath with the proper temperature of 113° to 115° F (45° to 46° C).

The home health nurse is observing a family member assist the patient with a heating pad. The nurse would intervene if the family member performs which action? A) Assists the patient to lie on the heating pad B) Adjusts the pad to the lowest temperature setting C) Places a cloth between the skin and the heating device D) Checks electrical cord for fraying or kinks

A) Assists the patient to lie on the heating pad

For an older female patient who is at risk for osteoporosis, which associated complication can be minimized by participating in a regular exercise program as prescribed by the health care provider (HCP)? A) Bone loss that results in fractures B) Immobility secondary to joint degeneration C) Tissue ischemia and pressure injuries D) Thrombophlebitis secondary to blood clots

A) Bone loss that results in fractures

What instructions would the nurse give to the UAP about applying a warm, moist compress to a small abscess in the patient's axilla? Select all that apply. A) Compress should be 105° to 110° F. B) Apply for 30-40 minutes. C) Report pain, exudate, or redness. D) Notify about completion of therapy. E) Evaluate the response to therapy.

A) Compress should be 105° to 110° F. C) Report pain, exudate, or redness. D) Notify about completion of therapy.

The new nurse observes an HCP who routinely comes out of a patient's room, goes to the sink, quickly soaps her hands, rinses, and then shakes water from her hands so that it splashes on the floor, sink, and her clothing. What would the new nurse do? A) Contact the infection-control nurse for advice. B) Do nothing because the HCP is not accountable to the nurse. C) Check on the patient's status and then write up an incident report. D) Offer the HCP a paper towel and assess understanding of hand hygiene.

A) Contact the infection-control nurse for advice.

Which instructions would the nurse give to a new home health aide about helping the patient who has problems of immobility? Select all that apply. A) Ensure that the patient wears shoes with a nonslip sole during ambulation and transfer. B) Assist the patient to make gradual position changes. C) If the patient has orthostatic hypotension, advise him to stay in bed. D) If the patient becomes faint or dizzy when walking, ease him to the floor or a chair. E) Be sure the home is free of clutter, wet areas, or rugs that may slide.

A) Ensure that the patient wears shoes with a nonslip sole during ambulation and transfer. B) Assist the patient to make gradual position changes. D) If the patient becomes faint or dizzy when walking, ease him to the floor or a chair. E) Be sure the home is free of clutter, wet areas, or rugs that may slide.

What is included in the proper method for disposal of sharps? Select all that apply. A) Everyone is responsible for disposing of sharps immediately after using them. B) Dispose of sharps in a puncture-proof container in the patient area. C) Drop sharps into container, avoid touching the rim. D) Carefully recap used needles in the home setting before disposing. E) Avoid pushing items into the container or overfilling it. F) Avoid leaving sharps on procedure trays or among bed linens.

A) Everyone is responsible for disposing of sharps immediately after using them. B) Dispose of sharps in a puncture-proof container in the patient area. C) Drop sharps into container, avoid touching the rim. E) Avoid pushing items into the container or overfilling it. F) Avoid leaving sharps on procedure trays or among bed linens.

Which range-of-motion (ROM) exercises can be safely performed on the neck? Select all that apply. A) Flexion B) Supination C) Lateral flexion D) Rotation E) Hyperextension

A) Flexion C) Lateral flexion D) Rotation

The patient experienced a stroke that left her with severe left-sided paralysis and very limited mobility. Which device would prevent plantar flexion? A) Footboard B) Bed board C) Trapeze bar D) Trochanter roll

A) Footboard

Which patient needs to be placed into contact precautions? A) Has a draining wound colonized with multidrug-resistant bacteria B) Has cancer and currently has leukopenia C) Has meningitis caused by invasive Neisseria meningitidis D) Has tuberculosis caused by Mycobacterium tuberculosis

A) Has a draining wound colonized with multidrug-resistant bacteria

The nursing student has been diagnosed with "strep throat." Under what circumstances can the student go to the clinical unit and care for patients and complete the clinical objectives? A) Has been taking prescribed antibiotics for at least 24 hours B) Agrees to wear a mask whenever caring for patients C) Cares only for patients who are not susceptible to infection D) Can return to clinical if the instructor is aware of the condition

A) Has been taking prescribed antibiotics for at least 24 hours

Which patient is most likely to request that the room temperature be turned down? A) Has chronic obstructive pulmonary disease B) Has alternating chills and fever C) Has peripheral vascular disease D) Has end-stage pancreatic cancer

A) Has chronic obstructive pulmonary disease

The nurse is caring for an older adult patient who requires assistance with elimination. He can walk very slowly, but is frequently incontinent of urine before he can get to the toilet. What would the nurse do to help the patient with elimination? Select all that apply. A) Instruct the UAP to be alert for the call signal and answer promptly. B) Obtain an order for an indwelling catheter until bladder training is achieved. C) Show the patient how to use a urinal and place it within his reach. D) Obtain an order for a commode chair and place it close to the bed. E) Restrict fluids to exact intervals to establish a voiding pattern. F) Make a plan with the patient to call sooner, rather than delaying.

A) Instruct the UAP to be alert for the call signal and answer promptly.

The nurse is assisting a patient who has poor balance to move from the bed to the chair. What is included in the correct technique for assisting the patient to stand and pivot to the chair? A) Keep the knees slightly bent. B) Maintain a narrow base with the feet. C) Keep the stomach muscles loose. D) Stand at arm's length from the patient.

A) Keep the knees slightly bent.

A patient with dementia needs assistance with bathing. What strategies are best to help the patient accomplish this task? Select all that apply.

A) Maintain a relaxed demeanor, smile frequently, and use a calm tone of voice. C) Reassure frequently and say things such as, "You are doing well. We are almost done." E) Use distraction rather than trying to negotiate or making demands. F) Attempt to have the same caregivers as often as possible for hygienic care.

Which position would be most comfortable for the patient and provide the best access for the nurse to insert a rectal suppository? A) Modified left lateral recumbent position B) Lithotomy C) Trendelenburg D) Orthopneic

A) Modified left lateral recumbent position

Which situation is the best example of proper ergonomic principles? A) Nurse A raises the head of the bed, supports the patient's shoulders, and helps to swing the legs around and off the bed using a pivoting motion. B) Nurse B rolls the patient onto his/her side. The nurse then stoops, and when standing, brings the patient along with the nurse. C) Nurse C gradually lowers the patient into the chair; the nurse bends his hips and knees as the patient leans slightly forward and sits down. D) Nurse D assesses for equipment such as IV lines, urinary catheters, or tubes and positions them to avoid tension during the transfer.

A) Nurse A raises the head of the bed, supports the patient's shoulders, and helps to swing the legs around and off the bed using a pivoting motion.

The nurse is observing a nursing student who is preparing to do a sterile dressing change. Which action requires correction and additional instruction?

A) Opening the outer flap of the sterile package by moving it toward the body

What is an early sign of acute compartment syndrome? A) Pain upon stretching B) Numbness C) Paralysis D) Cold, pale skin

A) Pain upon stretching

Which actions are essential? A) Performs hand hygiene after completing wound care and dressing change B) Washes hands and changes gloves between cleaning for perineal area and rectum C) Wears a mask and eye protection or a face shield while performing venipuncture D) Dons a clean, unsterile gown before caring for a patient with copious vomiting E) Handles laboratory specimens from all patients as if they are infectious F) Uses an alcohol-based hand cleanser after caring for a patient who has diarrhea related to Clostridium difficile G) Isolates patient with suspected airborne communicable disease and notifies the HCP

A) Performs hand hygiene after completing wound care and dressing change B) Washes hands and changes gloves between cleaning for perineal area and rectum E) Handles laboratory specimens from all patients as if they are infectious G) Isolates patient with suspected airborne communicable disease and notifies the HCP

The nurse is interviewing a patient at a walk-in clinic. The patient reports fatigue, weight loss, dyspnea, fever, night sweats, and coughing up small flecks of blood. What would the nurse do first? A) Put a mask on the patient and escort him to an isolation room. B) Don a mask, gown, and gloves and put a mask on the patient. C) Assess for history of respiratory disease or family history of cancer. D) Alert the HCP about the patient's symptoms.

A) Put a mask on the patient and escort him to an isolation room.

An unconscious patient needs oral care. What instructions would the nurse give to the UAP to ensure the safety of the patient? Select all that apply. A) Put the patient in a side-lying position; use pillows for support as needed. B) Report bleeding, sores in the mouth, or obvious problems with teeth or gums. C) Check for gag reflex by gently inserting a tongue blade into the throat. D) Use a soft toothbrush to clean inner and outer surfaces of teeth; swab mouth and tongue E) Have an oral suction device ready and check function prior to starting. F) Perform hand hygiene before donning clean gloves.

A) Put the patient in a side-lying position; use pillows for support as needed. B) Report bleeding, sores in the mouth, or obvious problems with teeth or gums. D) Use a soft toothbrush to clean inner and outer surfaces of teeth; swab mouth and tongue E) Have an oral suction device ready and check function prior to starting. F) Perform hand hygiene before donning clean gloves.

The nurse is evaluating the eye care that has been delegated to and is being provided by a new staff member. Which action is appropriate? A) Removing dried secretions with moist gauze B) Using soap and water on a washcloth C) Cleansing the eyes from the outer to the inner canthus D) Wiping plastic eyeglasses with a clean paper towel

A) Removing dried secretions with moist gauze

The nurse is assessing a patient who is immobile because of injuries sustained in a car accident. What areas does the nurse pay special attention to for the prevention and early detection of pressure injuries? Select all that apply. A) Sacrum B) Scapulae C) Trochanteric areas of the hips D) Heels E) Back of the head F) Sternum

A) Sacrum B) Scapulae C) Trochanteric areas of the hips D) Heels E) Back of the head

The nursing student is told to observe the bowel movements of an adult patient and report any abnormalities to the nurse. What would the student report as an unexpected finding? A) Stool was a dull clay color. B) Stool had soft, formed consistency. C) Patient reported three bowel movements this week. D) Stool had the shape of the rectum.

A) Stool was a dull clay color.

The nurse is supervising a new UAP in performing care for isolation patients. When is the nurse most likely to intervene? Select all that apply. A) The UAP wears a mask dangling around the neck and repositions it before entering patient's room. B) The UAP changes the mask every 20 to 30 minutes because it takes a long time to assist a patient. C) The UAP removes the mask by grasping the front portion that covers the mouth and pulling if off. D) The UAP wears an isolation gown over the uniform to provide an extra layer of warmth. E) The UAP pushes the sleeves of the isolation gown up while bathing a patient. F) The UAP reuses a mask when reentering the patient's room.

A) The UAP wears a mask dangling around the neck and repositions it before entering patient's room. C) The UAP removes the mask by grasping the front portion that covers the mouth and pulling if off. D) The UAP wears an isolation gown over the uniform to provide an extra layer of warmth. E) The UAP pushes the sleeves of the isolation gown up while bathing a patient. F) The UAP reuses a mask when reentering the patient's room.

Which patient has a condition that will be most challenging for the health care team to manage? A) The patient is immunocompromised and has a wound infected with MRSA. B) The patient has a throat infection and throat culture shows β-hemolytic group A streptococci. C) The patient has pelvic inflammatory disease caused by Neisseria gonorrhoeae. D) The patient handles an exotic animal hide and develops a skin lesion; culture shows Bacillus anthracis.

A) The patient is immunocompromised and has a wound infected with MRSA.

What is a general principle to consider when using heat and cold therapy for patients? A) The patient should be assessed for ability to perceive temperature in the area of the application. B) The patient should adjust the temperature settings for comfort. C) The patient should move the application around for relief. D) Application is positioned for convenient observation.

A) The patient should be assessed for ability to perceive temperature in the area of the application.

A sitz bath has been ordered for a patient with a history of recent vaginal delivery with extensive perineal lacerations. How would the nurse explain this treatment to the patient? A) The water should be as warm as possible. B) The purpose of the sitz bath is to cleanse and reduce inflammation. C) If sitz bath equipment is not available, a shower can be substituted. D) The patient should remain in the sitz bath for 5-10 minutes.

A) The water should be as warm as possible. B) The purpose of the sitz bath is to cleanse and reduce inflammation. C) If sitz bath equipment is not available, a shower can be substituted. D) The patient should remain in the sitz bath for 5-10 minutes

The nurse is assessing the oral cavity of an unconscious patient and sees tenacious, dried exudate on the tongue, teeth, and gums. Which instructions would be given to the UAP? A) Use a moistened sponge applicator and gently clean crusts several times per shift. B) Spray the mouth with a bulb syringe and use oral suction to remove the fluid. C) Use a toothbrush with paste and scrub the area until the crusts are removed. D) Wrap a gauze sponge around a tongue blade and apply hydrogen peroxide.

A) Use a moistened sponge applicator and gently clean crusts several times per shift.

The unlicensed assistive personnel (UAP) is assigned to disinfect equipment. Which instructions will the nurse give to the UAP about maintaining personal safety? Select all that apply. A) Wear gloves to protect skin and prevent breakdown. B) Follow manufacturer's instructions for dilution and use. C) Avoid using disinfectant if equipment is contaminated with spores. D) Assume equipment is contaminated and use Standard Precautions. E) Use an antiseptic solution if the disinfectant is not removing the debris. F) Discard any equipment that cannot be readily and safely cleaned and disinfected.

A) Wear gloves to protect skin and prevent breakdown. B) Follow manufacturer's instructions for dilution and use. D) Assume equipment is contaminated and use Standard Precautions.

The nurse is caring for a patient who is comatose after sustaining a severe head injury several months ago. He is breathing on his own and his vital signs are stable but he shows no purposeful movements. a. What are the complications of immobility for this patient?- Reduced Peristalsis

Anorexia (decreased appetite), Constipation, Disuse osteoporosis, Renal calculi (kidney stones), Urinary tract infection

What nursing intervention would you use to address thrombophlebitis or deep vein thrombosis (DVT)?

Antiembolism measures (thromboembolic deterrent [TED] hose or decompression boots)

The nurse is caring for several patients. The patients include a frail 87-year-old woman with a hip fracture; a 78-year-old woman with advanced Alzheimer's disease who is being treated for dehydration secondary to incontinence of watery diarrhea; and a 60-year-old man who sustained a small perforation during a routine colonoscopy, which was recommended as part of his annual physical examination. a. Explain conditions that promote the onset of HAIs for these patients.

Any patient can develop a health care-associated infection (HAI) if Standard Precautions are not consistently used. However, the patient with the hip fracture and the patient with dehydration and diarrhea are at a greater risk because of age, debilitation, poor nutritional status, and decreased mobility. The patient who underwent the routine colonoscopy should be further assessed for underlying chronic health problems that may contribute to risk for infection.

Identify how a patient that is an East Indian Hindu might be affected or altered by bathing

Assess the individual preferences of the patient. Some individuals of this background prefer a daily bath as part of religious duty; bathing after a meal or with water that is too hot may be avoided.

What are some examples of tasks that require "Clean technique" (medical asepsis)?

Assisting a patient with a meal tray/ Helping a patient brush the teeth/ Changing the bed linens/ Replacing a colostomy bag/ Removing medication from a bubble pack/ Suctioning the oral cavity

Which patient is the most challenging regarding maintaining sterile technique throughout the procedure? A) 4-month-old infant is crying and upset, and needs routine immunization B) 75-year-old woman is obese and confused and needs an indwelling urinary catheter inserted C) 50-year-old man is continuously coughing and needs a dressing change on upper chest D) 15-year-old cheerful patient with Down syndrome "wants to help" insert the IV The nurse is assisting an HCP by setting up a sterile tray for a procedure at the

B) 75-year-old woman is obese and confused and needs an indwelling urinary catheter inserted

Which of the following patients have an increased risk of a skin pressure injury? Select all that apply. A) A patient with obesity B) A patient who is underweight C) An incontinent patient D) A patient with a nasogastric tube in place E) A patient with a diagnosis of renal calculi F) A patient with a spinal cord injury

B) A patient who is underweight

With appropriate instructions and supervision, which tasks related to hygienic care could be delegated to experienced UAP? Select all that apply. A) A patient with diabetes wants to soak his feet in warm water. B) A patient with an indwelling urinary catheter needs assistance with pericare. C) A patient who is bed-bound would like to have his legs massaged after a bed bath. D) A patient on anticoagulant therapy is too unsteady to hold his disposable razor for shaving. E) A patient who is unconscious has secretions along the margins of the eyelids. F) A patient with peripheral vascular disease would like to have her toenails trimmed

B) A patient with an indwelling urinary catheter needs assistance with pericare. E) A patient who is unconscious has secretions along the margins of the eyelids.

The nurse is aware that the body has normal defenses against infection. Which medication can affect the acidic environment, which is one defense mechanism?

B) Aluminum/magnesium antacid

A visitor enters the nursing home without a mask. The nursing student politely hands her a disposable mask and suggests that social distancing decreases spread of the COVID-19 virus. The visitor refuses to comply. Which action is best for the nursing student to take? A) Give the visitor a brochure that explains the COVID-19 virus. B) Contact the charge nurse about the situation. C) Escort the visitor and the resident to a private room. D) Allow the visitor to have free choice and document the incident.

B) Contact the charge nurse about the situation.

The patient has a urinary tract infection. Which nursing intervention would enhance the normal defense mechanism of the urinary system? A) Instruct the patient to complete the prescription of antibiotics. B) Direct the patient to drink extra fluids to flush the urinary system. C) Monitor for and report fever and pain in the back or lower abdomen. D) Tell the patient that she will be notified about the urine culture.

B) Direct the patient to drink extra fluids to flush the urinary system.

Which health care facility is using evidencebased practice to protect patients and health care workers from musculoskeletal injuries? A) Hires unlicensed assistive personnel (UAP) who have at least 3 years experience and demonstrate proficiency in transferring and moving patients B) Has mechanical lifts available for use; there is at least an 80% compliance rate and nurses and UAP are trained in the use of devices C) Uses National Institute for Occupational Safety and Health (NIOSH) Division of Safety Research guidelines for designing exercise programs for older adults D) Places any patient who takes blood pressure medication on fall precautions and UAPs help those patients ambulate

B) Has mechanical lifts available for use; there is at least an 80% compliance rate and nurses and UAP are trained in the use of devices

The nurse is teaching a patient who has diabetes about foot care. What would be included in the self-care instructions? A) Carefully cut corns and apply moleskin. B) Inspect feet daily for breaks in the skin. C) Wear loose shoes or sandals to air the feet. D) Use alcohol on a gauze pad to clean between toes.

B) Inspect feet daily for breaks in the skin.

The nurse is caring for older adult residents in an assisted living facility. What is the best strategy to prevent skin breakdown among this vulnerable group? A) Make daily rounds and assess skin condition. B) Instruct UAP to help residents out of bed as much as possible. C) Plan a toileting schedule for the residents at greatest risk. D) Ask the dietary department to serve high- quality protein foods.

B) Instruct UAP to help residents out of bed as much as possible.

Immediately after donning a pair of gloves, a family member develops red, watery eyes and contact dermatitis with itching of the hands. What would the nurse do first? A) Inform the person that these are the signs/ symptoms of latex allergy. B) Instruct the person to remove the gloves and wash thoroughly with soap and water. C) Contact the HCP and observe for any signs of anaphylaxis. D) Assess for a personal or family history of latex allergy or other allergies.

B) Instruct the person to remove the gloves and wash thoroughly with soap and water.

What is the best rationale for the consistent use of Standard Precautions?

B) It is difficult to accurately identify all patients infected with blood-borne pathogens.

A cold application is ordered for the patient. What is a positive effect of this treatment? A) Vasodilation B) Local anesthesia C) Reduced blood viscosity D) Increased metabolism

B) Local anesthesia

Nurses are assigned a mixture of patients a who need isolation or just routine Standard Precautions. Which nurse has exposed his/her patients to infection via the indirect method of transmission? A) Nurse A first provides care for all of her patients who are not in isolation. B) Nurse B uses her personal stethoscope to assess all of her patients. C) Nurse C dons and doffs a new mask, gown, and gloves in caring for all of his patients. D) Nurse D washes his hands upon entering and exiting each patient's room.

B) Nurse B uses her personal stethoscope to assess all of her patients.

Which patient has a contracture? A) Patient has abnormal extension of a finger joint. B) Patient's wrist is abnormally flexed and joint is fixed. C) Patient's knee is hyperextended. D) Patient has abnormal lateral movements of ankle joint.

B) Patient's wrist is abnormally flexed and joint is fixed

The patient had a surgical procedure and is getting up to ambulate for the first time. While ambulating down the hallway, the patient says, "I'm going to faint." What would the nurse do first? A) Call out for someone to obtain a wheelchair.A) Call out for someone to obtain a wheelchair. B) Pull the patient close and lower him gently to the floor. C) Lean the patient against the wall until the episode passes. D) Support the patient and move quickly back to the room.

B) Pull the patient close and lower him gently to the floor.

When assessing the neurovascular status of a patient, what is an expected finding? A) Capillary refill after 8 seconds B) Pulses strong and easily palpated C) Loss of sensation to an affected area D) Mild localized discomfort

B) Pulses strong and easily palpated

Which instructions would the nurse provide to the UAP who will be bathing a patient with a hearing aid ? Select all that apply. A) Leave the hearing aid in place throughout the bathing process so the patient can hear instructions. B) Remove the hearing aid when washing the patient's hair. C) Clean the hearing aid with a soft dry cloth. D) Place the hearing aid on a sunny windowsill to air dry. E) Allow the patient to attempt to put the hearing aids back in after the bath. F) Notify the nurse if any drainage is noted in the ear.

B) Remove the hearing aid when washing the patient's hair. C) Clean the hearing aid with a soft dry cloth. E) Allow the patient to attempt to put the hearing aids back in after the bath. F) Notify the nurse if any drainage is noted in the ear.

The nurse is assisting an HCP by setting up a sterile tray for a procedure at the bedside. When the nurse opens the tray, there is moisture on a piece of equipment. What would the nurse do? A) Continue to set up the tray, because everything inside the kit is considered sterile. B) Return the entire tray to the supply area for resterilization and obtain a new tray. C) Put on a sterile glove and remove the moist piece of equipment and set it aside. D) Inform the HCP and obtain a new order for additional equipment.

B) Return the entire tray to the supply area for resterilization and obtain a new tray.

A patient is positive for human immunodeficiency virus (HIV) and ready for discharge. He expresses fears about exposure of other family members, particularly young children, to the disease. What is the best response to help decrease the patient's fears and concerns? A) Review general principles of infection control in the home setting. B) Review principles of mode of transmission for HIV. C) Encourage expression of fears and concerns and validate feelings. D) Suggest that the patient maintain contact with family using phone calls, email, or video conferencing.

B) Review principles of mode of transmission for HIV.

Which action by the nursing student requires correction because it contributes to the potential transmission of pathogens? A) Uses a dampened cloth to wipe off the overbed table B) Shakes linens to remove debris and then places them in laundry bag C) Holds soiled linens at a distance to prevent touching uniform D) Washes hands with soap and water after emptying and cleaning a bedpan

B) Shakes linens to remove debris and then places them in laundry bag

A patient who is paralyzed from the waist down is at risk for developing a pressure injury on the sacral area. Which intervention would the nurse use for this patient? A) Frequently check and change the bed linens. B) Teach to shift weight every 15 minutes. C) Obtain an order for a donut cushion for sitting. D) Keep skin moist and frequently reapply lotion.

B) Teach to shift weight every 15 minutes.

Which patient behavior should be corrected to reduce the risk of thrombophlebitis? A) The patient gets out of bed and forgets to put on slippers. B) The patient sits in chair and crosses legs while reading a book. C) The patient forgets to rise slowly when getting out of bed. D) The patient sits in a slouched position on a soft couch.

B) The patient sits in chair and crosses legs while reading a book.

. What is an expected change related to aging that necessitates more frequent oral hygiene for older adults? A) Older adults don't recognize that good dental health helps preserve their ability to eat. B) There is a decreased production of saliva and commonly an alteration in the sense of taste. C) Older adults tend to have more dental caries because teeth are less resistant to bacteria. D) There is a decreased ability to chew and digest raw fruits and vegetables that contribute to dental health.

B) There is a decreased production of saliva and commonly an alteration in the sense of taste.

The nurse has received report on a patient admission for possible sepsis resulting from a urinary tract infection. The patient is a 75-year-old male with very limited mobility. His medical history is significant for diabetes, hypertension, stroke, and asthma. His BMI is 20. He has an indwelling bladder catheter in place due to recent urinary retention. He also has a stage 2 pressure injury on his sacral area. The charac teristics of the stage 2 pressure injury that the nurse would note on assessment would include _______. A) undermining or tunneling B) shallow, shiny pink wound bed C) skin intact with nonblanchable redness D) subcutaneous fat is visible

B) shallow, shiny pink wound bed

Patients who are immobilized in health care facilities have psychosocial needs that must be met along with their physiologic needs. Which statement by the nurse acknowledges these needs? A) "Visiting hours will be limited so you can rest." B) "We will help you do everything so you don't have to worry." C) "Let's talk about what you used to do at home during the day." D) "A private room can be arranged for you."

C) "Let's talk about what you used to do at home during the day."

Which patient is most likely to be susceptible to infection because of factors affecting immunologic defense mechanisms? A) A 5-year-old child who is not up to date on school immunizations B) A 35-year-old woman who has recently returned from Japan C) A 73-year-old man who recently had chemotherapy and radiation treatments D) A 55-year-old man who has a high-stress job and is overweight

C) A 73-year-old man who recently had chemotherapy and radiation treatments

Which health care worker is most likely to be a vector of infection? A) A UAP removes a bag full of dirty laundry from a patient's room. B) A clinic nurse places a child exposed to measles at school in an isolated area. C) A nursing student has mild influenza symptoms but feels okay to go to the clinical experience. D) An HCP sees the last patient at the clinic and forgets hand hygiene before going home.

C) A nursing student has mild influenza symptoms but feels okay to go to the clinical experience.

For which circumstance would it be appropriate to contact the infection-control nurse for assistance?

C) An unusual cluster of infection is seen in the emergency department.

The nurse is caring for a postpartum patient. Which assessment would the nurse perform first before starting perineal care? A) Note presence of accumulated secretions. B) Evaluate the appearance of the perineum. C) Assess ability to perform own care. D) Ask about burning with urination.

C) Assess ability to perform own care.

The nurse is caring for an obese patient who needs assessment of skin and self-care abilities. The patient also needs perineal care, partial bath, and the bed linen changed. What is the best strategy to meet the needs of the patient? A) Instruct the UAP to perform all tasks except the skin assessment. B) Ask the UAP to call when the patient's back is positioned for assessment. C) Assess skin and self-care abilities while working with the UAP to complete care. D) Assess skin and self-care abilities, then tell the patient to perform her own care.

C) Assess skin and self-care abilities while working with the UAP to complete care.

The patient has a cast on the left lower leg. Which assessment is performed to prevent compartment syndrome? A) Assess the patient's ability and willingness to assist with mobility. B) Assess muscle strength, activity tolerance, body position, and ROM. C) Assess skin color, temperature, movement, sensation, pulses, capillary refill, and pain. D) Assess patient's understanding of cast care and complications of immobility.

C) Assess skin color, temperature, movement, sensation, pulses, capillary refill, and pain.

The nurse sees the UAP trying to take an overly full laundry bag from the patient's room to the dirty utility room. The UAP is struggling to manage the bag and is partially dragging it on the floor. What would the nurse do? A) Allow the UAP to continue because she is completing her duties. B) Report the UAP for creating a situation where proper handling is impossible. C) Assist the UAP to carry the bag and then find out how it got so overfilled. D) Remind the UAP that overfilling the bag creates a problem for proper disposal.

C) Assist the UAP to carry the bag and then find out how it got so overfilled.

The nurse will delegate denture care to the unlicensed assistive personnel (UAP). What instructions would the nurse give to the UAP about the patient's dentures? A) Use hot water and a mild soap. B) Let the patient wear them at night. C) Brush dentures with a soft toothbrush. D) Wrap them in a soft towel when not worn.

C) Brush dentures with a soft toothbrush.

The nurse is assessing a patient being admitted from another institution for the presence of pressure injuries. Which of the following statements is correct? A) A reddened area of the skin is considered a pressure injury. B) Pressure injuries are apparent upon inspection of the skin. C) Documentation should include measurements and description of any injuries. D) The patient should be assessed in prone position as most pressure injuries are on the back.

C) Documentation should include measurements and description of any injuries.

Which patient is most likely to need neutropenic precautions? A) Has hepatitis A and is incontinent of bowels and bladder B) Has chronic wound with methicillin- resistant Staphylococcus aureus (MRSA) infection C) Has leukopenia with fewer than 3,500 white blood cells per microliter. D) Has a flat red rash and cold symptoms and sibling has measles.

C) Has leukopenia with fewer than 3,500 white blood cells per microliter.

The nurse observes the patient performing ear care. Which behavior indicates a need for additional teaching? A) Cleans the pinna with a cotton-tipped swab B) Turns the hearing aid off when not in use C) Leaves the hearing aid by a sunny window D) Rotates a clean washcloth to clean ear canal

C) Leaves the hearing aid by a sunny window

A patient comes into the clinic and tells the nurse that he has a sore throat and would like to see an HCP. For which tasks does the nurse need to wear gloves? Select all that apply. A) Interview and taking a history B) Taking the patient's radial pulse C) Measuring an oral temperature D) Taking a throat swab for culture E) Reviewing the patient's home medications F) Using a tongue blade to look at the throat

C) Measuring an oral temperature D) Taking a throat swab for culture F) Using a tongue blade to look at the throat

Which medications are most likely to contribute to orthostatic hypotension? A) Medications used to treat osteoporosis B) Medications used to prevent thrombophlebitis C) Medications used to reduce high blood pressure D) Medications used to treat arthritis pain

C) Medications used to reduce high blood pressure

Which patient is the most likely candidate for active assisted ROM exercises? A) Patient A is difficult to arouse but is responsive to painful stimuli. B) Patient B is able to move but is very depressed and reluctant to participate. C) Patient C has right-sided weakness in the upper body due to a stroke. D) Patient D is alert and oriented but is very frail and debilitated.

C) Patient C has right-sided weakness in the upper body due to a stroke.

The nurse had a previous back injury and knows that she should avoid twisting her spine as she cares for patients. What is the best strategy for the nurse to use? A) Ask to be assigned to patients who are self-mobile. B) Direct the UAP to do any heavy lifting. C) Stand directly in front of the person or object being worked with. D) Take antiinflammatory pain medication before assisting patients.

C) Stand directly in front of the person or object being worked with.

The nurse is preparing to assist the patient to transfer from the bed to the chair. Which action demonstrates the nurse's proper use of body mechanics? A) Stands by the chair and reaches out to guide the patient toward the chair B) Stands by the side of the patient and pulls up on the stronger arm C) Stands directly in front of the patient and places hands at the patient's waist level D) Stands to the side of patient and assists as the patient pivots

C) Stands directly in front of the patient and places hands at the patient's waist level

The nurse applies heat to a large area on the patient's trunk. The patient reports feeling slightly dizzy and his pulse is rapid. What is the best physiologic explanation for this systemic reaction? A) The heat application has triggered a fever. B) The trunk contains some large blood vessels. C) The application is causing vasodilation. D) Antibodies and leukocytes are activated.

C) The application is causing vasodilation.

The care plan indicates that all caregivers should encourage the patient's independence in accomplishing activities of daily living (ADLs). What is the best indication that the nurses and UAP are successful with this part of the care plan? A) The UAP waits until the patient uses the call light for assistance. B) The nurse sees that the commode chair is close to the bed. C) The nurse observes that the patient is brushing his own teeth. D) The UAP tells the patient to independently complete ADLs.

C) The nurse observes that the patient is brushing his own teeth.

The patient was diagnosed with a sprained ankle and the provider recommended a cold application for 20 minutes. Which condition would cause the nurse to question the order? A) The patient's ankle is already slightly swollen. B) The pain medication has not had time to work. C) The patient has a history of peripheral vascular disease. D) The patient tells the nurse that 20 minutes is too long.

C) The patient has a history of peripheral vascular disease..

Which patient is showing signs of an inflammatory response in the absence of infection? A) The patient has sore throat and hoarse voice that are resolving with antibiotic therapy. B) The patient has burning with urination and urine appears cloudy with a strong odor. C) The patient's ankle is swollen, red, and tender; symptoms started after falling. D) The patient's eye is red and irritated; he wakes with a crusty, yellow drainage.

C) The patient's ankle is swollen, red, and tender; symptoms started after falling.

Which would be the most important factor to consider when planning personal hygiene for a patient from a cultural background that the nurse has not previously worked with? A) The country of origin of the patient B) The language the patient prefers to speak C) The patient's individual preferences D) The reports that came with the patient from a previous institution

C) The patient's individual preferences

What would be included in the care of a patient with incontinence and rotavirus? A) A private room with negative airflow B) Hand hygiene after filtration masks are removed C) Use of gloves and gown upon entering the room D) Use of a surgical mask on the patient during transfers

C) Use of gloves and gown upon entering the room

Which actions are nonessential? A) Performs hand hygiene after completing wound care and dressing change B) Washes hands and changes gloves between cleaning for perineal area and rectum C) Wears a mask and eye protection or a face shield while performing venipuncture D) Dons a clean, unsterile gown before caring for a patient with copious vomiting E) Handles laboratory specimens from all patients as if they are infectious F) Uses an alcohol-based hand cleanser after caring for a patient who has diarrhea related to Clostridium difficile G) Isolates patient with suspected airborne communicable disease and notifies the HCP

C) Wears a mask and eye protection or a face shield while performing venipuncture

The patient has been receiving antibiotic therapy. Which laboratory result indicates the need to contact the health care provider (HCP) for a reevaluation of prescribed therapy?

C) White blood cell count is elevated.

The nurse has received report on a patient admission for possible sepsis resulting from a urinary tract infection. The patient is a 75-year-old male with very limited mobility. His medical history is significant for diabetes, hypertension, stroke, and asthma. His BMI is 20. He has an indwelling bladder catheter in place due to recent urinary retention. He also has a stage 2 pressure injury on his sacral area. The factors in the patient's history that put him most at risk for pressure injury are _______. A) immobility, age 75, and asthma B) age 75, BMI 20, and diabetes C) immobility, possible sepsis, and age 75 D) urinary retention, immobility, hypertension

C) immobility, possible sepsis, and age 75

The nurse notices a reddened area on the patient's sacrum. What would the nurse do first? A) Cleanse the skin with alcohol. B) Wash the area with warm water and soap. C) Massage the area to stimulate blood flow. D) Assess for other areas of erythema.

D) Assess for other areas of erythema.

A family member tells the nurse that the staff is spending too much time laughing and chatting at the nurses' station and it is disturbing the patient's rest and comfort. What would the nurse do first? A) Instruct the staff to be more discreet and move conversation to the breakroom. B) Assess other environmental factors that are interfering with patient's comfort. C) Apologize to the family member and assure that the situation will be corrected. D) Assess the patient's discomfort and ask what other things are interfering with rest.

D) Assess the patient's discomfort and ask what other things are interfering with rest.

The patient has a large midline abdominal incision. With the specific purpose of reducing a possible reservoir of infection, what would the nurse do? A) Wear gloves and mask at all times. B) Isolate the patient's personal articles. C) Direct the patient to cover mouth when coughing. D) Change the dressing when it becomes soiled.

D) Change the dressing when it becomes soiled.

The patient has tuberculosis and has been placed in a negative-pressure isolation room with airborne precautions. Despite patient education, he slips out of his room and goes outside to smoke cigarettes. What would the nurse do first? A) Obtain an order for an around-the-clock sitter. B) Report the patient's behavior to the infection-control nurse. C) Ask the HCP to prescribe a nicotine patch. D) Discuss the behavior with the patient.

D) Discuss the behavior with the patient.

A new resident has been admitted to a longterm care facility. What is the most important thing for the nurse to assess before delegating oral hygiene to the UAP? A) Does the resident have adequate supplies, such a soft-bristled toothbrush and nonalcohol-based mouthwash? B) Does the UAP understand how to assist the resident and maximize the resident's independent efforts? C) Does the resident actually want and need assistance or is self-care more appropriate? D) Does the resident have a gag reflex and is he able to spit out residue from toothpaste and mouthwash?

D) Does the resident have a gag reflex and is he able to spit out residue from toothpaste and mouthwash?

Which actions are contraindicated? A) Performs hand hygiene after completing wound care and dressing change B) Washes hands and changes gloves between cleaning for perineal area and rectum C) Wears a mask and eye protection or a face shield while performing venipuncture D) Dons a clean, unsterile gown before caring for a patient with copious vomiting E) Handles laboratory specimens from all patients as if they are infectious F) Uses an alcohol-based hand cleanser after caring for a patient who has diarrhea related to Clostridium difficile G) Isolates patient with suspected airborne communicable disease and notifies the HCP

D) Dons a clean, unsterile gown before caring for a patient with copious vomiting F) Uses an alcohol-based hand cleanser after caring for a patient who has diarrhea related to Clostridium difficile

The patient will be immobilized for an extended period due to extensive injuries. Which intervention will the nurse use to prevent respiratory complications? A) Suction the airway every hour. B) Change the patient's position every 4-8 hours. C) Use oxygen and nebulizer treatments regularly. D) Encourage deep-breathing and coughing every hour.

D) Encourage deep breathing and coughing every hour.

In delegating the early morning care that should occur before breakfast, what does the nurse remind the UAP to do for the patient? A) Shampoo the patient's hair and comb it. B) Assist the patient with a bath and clean gown. C) Offer the patient a backrub with warmed lotion. D) Help the patient wash hands and face.

D) Help the patient wash hands and face.

A patient with rubella needs to be transported to the radiology department. What would the nurse do to prepare the patient for transport? A) Advise the patient to immediately wash hands after returning from procedure. B) Call the radiology department and inform them to wear gloves at all times. C) Dress the patient in an isolation gown and then apply a mask. D) Instruct the patient to wear a mask and follow cough etiquette.

D) Instruct the patient to wear a mask and follow cough etiquette.

Which nurse is using the key factor in body mechanics? A) Nurse A keeps head aligned and bends straight over at the waist to assist the patient to tie his shoelaces. B) Nurse B puts one leg slightly behind other, bends knees, and uses large leg muscles to boost a box to a high shelf. C) Nurse C reaches across the bed to support patient's back and shoulders as he dangles his feet for several minutes. D) Nurse D keeps head erect and aligns and balances weight on both feet when assisting a patient to stand up.

D) Nurse D keeps head erect and aligns and balances weight on both feet when assisting a patient to stand up.

The nurse is assigned to care for some patients who are in isolation and some who are not. What would the nurse do to meet the needs of all the patients? A) Provide care for patients who are not in isolation first. B) Ask the charge nurse to reassign at least one of the isolation cases to another nurse. C) See if patients with same type of isolation can be rearranged to be roommates. D) Organize and cluster care of isolation patients to minimize donning and doffing gowns.

D) Organize and cluster care of isolation patients to minimize donning and doffing gowns.

When caring for a patient with tuberculosis who is on airborne precautions, what would the nurse routinely use? A) Regular mask and eyewear B) Gown and gloves C) Surgical handwashing and gloves D) Particulate respirator mask

D) Particulate respirator mask

The nurse is helping plan an activity schedule for an older adult resident at a long-term care facility who is at risk for disuse syndrome. Which plan is the nurse most likely to suggest? A) Ten minutes of warmup and stretching, followed by 45 minutes of mild aerobic exercise, followed by 10 minutes of cool-down exercises performed 3 days a week B) Twenty minutes of walking on Mondays, Wednesdays, and Fridays and 10-15 minutes of moderate weight training on Tuesdays and Thursdays C) Patient participation in active assisted ROM for uninvolved joints for 10 minutes; alternate every 2 hours with passive assisted ROM on involved joints for 10 minutes D) Patient participation in activities of daily living (ADLs) (e.g., combing hair, walking to bathroom) for 10-15 minutes every 2-3 hours while awake for a total of 2 hours of activity per 24 hours

D) Patient participation in activities of daily living (ADLs) (e.g., combing hair, walking to bathroom) for 10-15 minutes every 2-3 hours while awake for a total of 2 hours of activity per 24 hours

The first-year nursing students are going to the hospital for their first clinical experience. What is the most important thing that the students would do to prevent exposing patients to health care-associated infections (HAIs)? A) Understand how to care for patients who are in different kinds of isolation. B) Ensure that personal immunizations are up to date and health status is good. C) Know the steps for sterile technique and practice before going to clinical. D) Perform hand hygiene using recommendations from the CDC.

D) Perform hand hygiene using recommendations from the CDC.

The nurse is supervising a nursing student who is giving a patient a bed bath. The nurse would intervene if the student performed which action? A) Lowers the side rail to perform care B) Raises the head of the bed to a semi-Fowler's position C) Bathes arms using long, firm strokes D) Puts up all four side rails after completing the bath

D) Puts up all four side rails after completing the bath

A nurse walks into the patient's room and notices that the patient is having trouble breathing. Which position will the nurse use to help relieve the patient's respiratory distress? A)Lower the head of the bed and place the patient in a supine anatomical position. B) Position the patient on the side with knee and thigh drawn up toward the chest. C) Lower the patient's head and place the body and legs on a slightly inclined plane. D) Raise the head of the bed to 90 degrees and have the patient lean forward on the overbed table.

D) Raise the head of the bed to 90 degrees and have the patient lean forward on the overbed table.

What is the most likely complication when an older adult patient gets pulled across the bed when changing wet linens? A) Dislocation of a joint B) Increased stress to the joints C) Abnormal hyperextension of a joint D) Shearing or tearing of the skin

D) Shearing or tearing of the skin

The nurse is supervising a nursing student who is setting up a sterile tray to suction a patient. When would the nurse intervene? A) Student sets up the field on a clean overbed table that is at waist-level. B) Student touches the outside of the sterile wrapper when handling the package. C) Student picks up a sterile drape by the corner and lets it unfold by itself without touching any object. D) Student puts on sterile gloves, opens the bottle, and sets the cap on the sterile field.

D) Student puts on sterile gloves, opens the bottle, and sets the cap on the sterile field.

The nurse performs hand hygiene before donning gloves, completes the procedure, and then doffs the gloves. What is the best rationale for performing hand hygiene after doffing the gloves and before leaving the patient's room? A) The patient sees that the nurse is cautious and consistent about hand hygiene. B) The nurse may suddenly have to attend to another patient immediately upon exiting the room. C) The CDC recommends this final step to complete the procedure. D) There is a risk of perforating the gloves during use and the perforation may not be obvious.

D) There is a risk of perforating the gloves during use and the perforation may not be obvious.

Scenario: The nurse has received report on a patient admission for possible sepsis resulting from a urinary tract infection. The patient is a 75-year-old male with very limited mobility. His medical history is significant for diabetes, hypertension, stroke, and asthma. His BMI is 20. He has an indwelling bladder catheter in place due to recent urinary retention. He also has a stage 2 pressure injury on his sacral area. In addition to the ointment ordered by the health care provider, the nurse would provide the following interventions for the care of the pressure injury: _______. A) turn and reposition patient every 3 hours B) instruct patient to reposition himself every 15 minutes C) place patient in full lateral position D) assure adequate nutrition and fluid intake

D) assure adequate nutrition and fluid intake

What nursing intervention would you use to address orthostatic hypotension?

Dangle over side of bed

What nursing intervention would you use to address hypostatic pneumonia?

Deep-breathing and coughing exercises

Describe the procedure for gowning for contact isolation- 5th step

Discard soiled gown appropriately. (Prevents contamination.)

Describe the procedure for gowning for contact isolation- 3rd step

Don gown and tie it securely at neck and waist. (Provides protective covering of the entire uniform)

A 30-year-old female patient has quadriplegia secondary to a diving accident that occurred 5 years ago. She was very healthy and athletic prior to the accident, but within the last several months, she has been hospitalized several times for recurrent urinary tract infections and significant weight loss. She currently has a poor appetite. The nurse observes suspected deep tissue injury on the patient's right heel. Describe the criteria for suspected deep tissue injury.

During suspected deep tissue injury, the wound appears as a localized purple or maroon area of discolored, intact skin or a blood-filled blister. Characteristics of the area range from painful, firm, mushy, boggy, 32or warm to cool compared to adjacent tissue. The wound sometimes becomes covered with thin eschar.

Identify how a patient that is paralysed on there right-side due to a stroke might be affected or altered by bathing

Encourage the patient to do as much hygienic care as possible with the left arm, assisting as necessary.

What nursing intervention would you use to address contractures?

Footboard, trochanter roll, hand rolls, splinting devices

The nurse is caring for a patient who is comatose after sustaining a severe head injury several months ago. He is breathing on his own and his vital signs are stable but he shows no purposeful movements. c. During morning hygiene, the nurse notes a reddened area on the patient's sacrum. What nursing interventions can be used to address this finding?

For a reddened area on the sacrum, provide skin care and turning and supportive devices. Appearance of area and care must be carefully documented. Consult a wound care specialist as needed

What nursing intervention would you use to address disuse osteoporosis?

Frequent ambulation

The nurse is caring for several patients. The patients include a frail 87-year-old woman with a hip fracture; a 78-year-old woman with advanced Alzheimer's disease who is being treated for dehydration secondary to incontinence of watery diarrhea; and a 60-year-old man who sustained a small perforation during a routine colonoscopy, which was recommended as part of his annual physical examination. b. What measures can be used to prevent HAIs?

HAIs are primarily transmitted by contact between health care personnel and patients; thus hand hygiene is essential. Strict adherence to sterile technique is required for invasive procedures. Provide patients with items for personal care that are not shared with other patients (e. g., urinal or water pitcher). Place contaminated articles such as linen in designated receptacles. Teach patients and visitors about hand hygiene and isolation procedures. Staff education, review of infection procedures and policies, review of patient records, and consultation with infection-control nurse contribute to decreased incidence of HAIs. Analyzing data and consultation with public health departments helps alert staff about epidemiologic trends.

The nurse is caring for a 35-year-old patient who sustained a penetrating abdominal wound and multiple bruises and contusions in a farming accident. The abdominal wound was very contaminated, but cleaned before and during surgery. The wound-care specialist has been consulted and has taught the nursing staff how to do the dressing changes. The patient has a peripheral IV and is receiving IV antibiotics and pain medication. The nurse identifies that the patient is at risk for infection. c. Describe the signs and symptoms that would occur if the patient developed a localized infection at the abdominal wound site or at the IV site.

Localized—edema, pain, erythema, heat, pain/tenderness, purulent drainage

What nursing intervention would you use to address pressure injury?

Meticulous skin care

The nurse is caring for a patient who is comatose after sustaining a severe head injury several months ago. He is breathing on his own and his vital signs are stable but he shows no purposeful movements. a. What are the complications of immobility for this patient?- Muscle atrophy

Muscles decrease in size and strength when not continually used.

A 30-year-old female patient has quadriplegia secondary to a diving accident that occurred 5 years ago. She was very healthy and athletic prior to the accident, but within the last several months, she has been hospitalized several times for recurrent urinary tract infections and significant weight loss. She currently has a poor appetite. Identify general guidelines for care of pressure injuries.

Never massage reddened areas (risk of further skin breakdown) / Massage over bony prominences is no longer recommended (Massage results in decreased blood flow and tissue damage in some patients.) /Nutritional support, which promotes healthy tissue repair, is likely to be as important as local wound care for the patient. Observe the patient's hydration. If it is inadequate or if signs of dehydration (decreased skin turgor and recessed eyes) are present, encourage fluid intake, carefully observe and document the patient's intake and output (I&O), and monitor fluid replacement therapy as ordered./ Turn patients who are on complete bed rest or unable to reposition themselves every 2 hours. It is important to avoid the full lateral position, which results in direct pressure on the trochanteric region. The 30-degree lateral-incline position is preferable Reposition chair-bound patients every hour. If chair-bound patients are able to shift their weight, teach them to do so every 15 min. Place patients who are at risk for skin impairment on a pressure-relieving mattress or chair cushion. Doughnut types of cushions are not advisable because they sometimes cause a congestion of blood to the area, resulting in edema and decreased blood flow to the area. Placement of a rolled bath blanket under the distal extremity helps prevent pressure injuries on the heel by "floating" the heel (raises the heel off the bed) / Other pressure-relieving devices to try are therapeutic beds and mattresses. Examples of pressure-relieving beds are low-air-loss beds and oscillating support surface beds. In addition, there are the alternating air mattress and the water mattress. Many kinds of topical agents to facilitate healing are available to apply to the wound and edges of the wound. Take care to evaluate the effectiveness of any product used on the injury. Use with caution any products that have the capacity to damage fragile skin and prevent epithelialization (formation of new cells), such as hydrogen peroxide or alcohol

The nurse is caring for a patient who is comatose after sustaining a severe head injury several months ago. He is breathing on his own and his vital signs are stable but he shows no purposeful movements. b. What nursing interventions may be implemented to prevent the occurrence of complications of immobility?

Nurses can prevent complications by turning patients every 1-2 hours, providing range-of-motion exercises, obtaining a prescription for laboratory studies to assess nutritional status (i. e., albumin), obtaining nutritional consult as needed, and obtaining a prescription for a specialized mattress or a sheepskin covering.

What are some examples of tasks that require "sterile techinque" (surgical asepis) and why?

Obtaining a urine specimen from an existing catheter (Interior of syringe, tip and interior of needless adapter, and interior of specimen container are sterile.) / Obtaining a throat swab for a culture (Tip of cotton swab and interior of specimen container are sterile.) / Inserting a urinary catheter (Requires sterile gloves, field, and equipment.) / Drawing up medication in a syringe (Interior of syringe, entire needle, and interior of medication vial are sterile.) / Dressing change of a new surgical incision (Requires sterile gloves, field, and equipment.) / Suctioning the lower airway (Requires sterile gloves, field, and equipment.)

The nurse is caring for a patient who is comatose after sustaining a severe head injury several months ago. He is breathing on his own and his vital signs are stable but he shows no purposeful movements a. What are the complications of immobility for this patient? - postural hypotension

Orthostatic hypotension

Identify how a patient that is on complete bedrest might be affected or altered by bathing

Patient on complete bedrest—Assist as necessary with the bath and other hygienic measures such as oral care while the patient is in bed.

Describe the procedure for gowning for contact isolation- 2nd step

Perform hand hygiene. (Reduces spread of microorganisms.)

Identify how a patient that is extremely fatigued might be affected or altered by bathing

Perform only the care that is absolutely necessary for comfort and safety.

A 30-year-old female patient has quadriplegia secondary to a diving accident that occurred 5 years ago. She was very healthy and athletic prior to the accident, but within the last several months, she has been hospitalized several times for recurrent urinary tract infections and significant weight loss. She currently has a poor appetite. How can the nurse prevent the development of pressure injuries?

Pressure injuries can be prevented by repositioning the patient frequently in the bed or chair, providing good nutrition, keeping the skin clean and dry, and using pressurerelieving surfaces.

Describe the procedure for gowning for contact isolation- 1st step

Push up long sleeves, if you have them. (Ensures that the uniform sleeve is under the gown sleeve for protection.)

What nursing intervention would you use to address muscle atrophy?

Range-of-motion exercises

Describe the procedure for gowning for contact isolation- 4th step

Remove gown after providing necessary patient care. (Has protected the nurse.)

A 30-year-old female patient has quadriplegia secondary to a diving accident that occurred 5 years ago. She was very healthy and athletic prior to the accident, but within the last several months, she has been hospitalized several times for recurrent urinary tract infections and significant weight loss. She currently has a poor appetite. Identify possible risk factors that will contribute to development of pressure injuries for this patient..

Risk factors for development of pressure injuries include chronic illness, debilitation, limited mobility, incontinence, and poor nutrition

Identify how a patient that is an older adult who is incontinent might be affected or altered by bathing

Special care should be given to cleanse and dry the skin carefully; perineal care may be done more frequently, and a skin barrier cream can be applied.

A 30-year-old female patient has quadriplegia secondary to a diving accident that occurred 5 years ago. She was very healthy and athletic prior to the accident, but within the last several months, she has been hospitalized several times for recurrent urinary tract infections and significant weight loss. She currently has a poor appetite. The nurse observes a stage I pressure injury on the patient's sacral area. Describe the criteria for a stage I pressure injury.

Stage I is intact skin with nonblanchable redness. The wound characteristics vary: areas may be painful, firm, soft, warm, or cool compared to adjacent tissue.

What nursing intervention would you use to address disorientation?

Suitable diversion, stimulation, socialization

The nurse is caring for a 35-year-old patient who sustained a penetrating abdominal wound and multiple bruises and contusions in a farming accident. The abdominal wound was very contaminated, but cleaned before and during surgery. The wound-care specialist has been consulted and has taught the nursing staff how to do the dressing changes. The patient has a peripheral IV and is receiving IV antibiotics and pain medication. The nurse identifies that the patient is at risk for infection. d. Describe the signs and symptoms that would signal a systemic infection.

Systemic—fever, leukocytosis, malaise, anorexia, nausea, vomiting, lymph node enlargement (possibly change in mental status, although more likely to occur in older patients)

The nurse is caring for a 35-year-old patient who sustained a penetrating abdominal wound and multiple bruises and contusions in a farming accident. The abdominal wound was very contaminated, but cleaned before and during surgery. The wound-care specialist has been consulted and has taught the nursing staff how to do the dressing changes. The patient has a peripheral IV and is receiving IV antibiotics and pain medication. The nurse identifies that the patient is at risk for infection. b. Explain why this patient is likely to have an inflammatory response and describe the physiologic process that will occur.

The inflammatory process begins in response to injury or infection, with the cellular response and protective vascular reaction. Fluid, blood products, and nutrients are delivered to the interstitial tissues at the site of the injury. Pathogens are neutralized, allowing cell and tissue repair.

The nurse is caring for several patients. The patients include a frail 87-year-old woman with a hip fracture; a 78-year-old woman with advanced Alzheimer's disease who is being treated for dehydration secondary to incontinence of watery diarrhea; and a 60-year-old man who sustained a small perforation during a routine colonoscopy, which was recommended as part of his annual physical examination. c. Although the HCP has not currently ordered isolation precautions for any of these patients, the nurse should consider initiating isolation precautions for which patient? Identify the type of isolation that the nurse would choose and give the rationale that supports the decision.

The patient with watery diarrhea should be placed on contact precautions. Clostridium difficile (C. diff.) infection may be the cause. C. diff. infection is more common among older institutionalized patients. The HCP should be notified and an order for stool cultures should be obtained.

The nurse is caring for a patient who is comatose after sustaining a severe head injury several months ago. He is breathing on his own and his vital signs are stable but he shows no purposeful movements a. What are the complications of immobility for this patient? Complications of immobility include muscle atrophy, contractures, pressure injuries, reduced peristalsis, and postural hypotension. - Pressure ulcer:

Tissue ischemia (lack of blood flow to an area)

What nursing intervention would you use to address Urinary tract infection?

Up to bathroom at regular intervals

The nurse is caring for a patient who is comatose after sustaining a severe head injury several months ago. He is breathing on his own and his vital signs are stable but he shows no purposeful movements. a. What are the complications of immobility for this patient?- Contractures:

When muscles, ligaments, and tendons are not shortened and lengthened with movement, a permanent shortening of these structures may occur.

Surgical asepsis destroys....

all microorganisms.

Sterile technique is required to....

prevent introduction of organisms.

Medical asepsis includes...

techniques that inhibit the growth and spread of pathogens.