Mr. Griffin Pre-Simulation vSim Quiz

Which factors increase a postoperative patient's risk of infection? (Select all the apply) a) Weight b) Immunosuppression c) Presence of an incision d) Age e) Presence of pain

a, b, c, d Explanation: Any factor that interferes with normal healing or provides an entry for infectious agents is a risk factor for infection; such factors include obesity, aging, incisions, and being immunosuppressed. Pain itself is not a risk factor.

When bathing a patient who requires contact and droplet precautions, which personal protective devices (PPD) will the nurse put on? (Select all that apply) a) Mask b) Gown c) HEPA respirator d) Gloves e) Googles

a, b, d Explanation: Gloves, gown, and mask are the necessary PPD to wear in this situation. HEPA respirators are required when airborne precautions are required. Goggles are needed when there is a risk of splatter of blood or body fluids into the eyes of the caregiver.

When considering a 40-year-old postoperative patient, which factor is likely to present the greatest risk for the development of an infection? a) Invasive or indwelling medical procedures or devices b) Integrity and number of the patient's white blood cells c) Patient's age, gender, and race d) The pH levels of the body's gastrointestinal and genitourinary tracts

a) Invasive or indwelling medical procedures or devices Explanation: The use of invasive or indwelling medical devices, which provide exposure to, and entry for, more potential sources of disease-producing organisms, are particularly risky in a patient whose defenses are already weakened by disease or trauma, such as surgery. The remaining options represent factors that would contribute to the development of an infection when invasive or indwelling medical devices are utilized in the postoperative patent's care.

Which statement is true about transient bacteria? (Select all that apply) a) Occurs commonly on hands b) Relatively few are found on clean areas of skin c) Found in greatest numbers under the fingernails d) Can be removed easily through frequent, effective hand washing e) Requires friction with a brush to assure removal

a, b, c, d Explanation: Transient bacteria is commonly found on hands, especially on unclean areas and beneath the fingernails. They can be easily removed with frequent and thorough hand washing. Resident bacteria cling more stubbornly to the skin and require friction to assure removal.

Which interventions will the nurse implement when maintaining medial asepsis? (Select all that apply) a) Keep personal fingernails short b) Do not place soiled bed linen on the floor c) Allow only sterile items to touch sterile items d) Clean the least soiled areas first e) Practice good hand hygiene

a, b, d, e Explanation: Principles of medical asepsis include good hand hygiene; keeping nails short; cleaning from least soiled to most soiled; and never placing contaminated items on the floor (which would cause contamination to spread). Allowing only sterile items to be touched by sterile items is a principle of surgical asepsis.

Which statement best defines a human infection? a) A pathological condition that elevates the body's internal temperature above its baseline b) A disease state that is a result of pathogens in or on the body c) The presence of an illness that can spread from one human to another d) The result of the presence of bacteria, viruses or fungi in the body

b) A disease state that is a result of pathogens in or on the body Explanation: An infection is a disease state that results from the presence of pathogens (disease-producing microorganisms) in or on the body. While the remaining options describe factors associated with an infection, none describes an infection as completely as the correct option.

The nurse is conducting a neurovascular assessment on a postoperative patient who experienced a total knee arthroplasty (TKA). What is the nurse's initial intervention when it appears that there is an absence of a pulse in the affected foot? a) Assess for paresthesia in the affected extremity b) Assess the capillary refill in both longer extremities c) Notify the patient's health care provider of the assessment finding d) Elevate the affected extremity

b) Assess the capillary refill in both longer extremities Explanation: Assess capillary refill, comparing the findings of both extremities in order to evaluate arterial blood flow. Elevation of the affected extremity is directed towards minimizing edema and encouraging venous return. The nurse should notify the health care providers when all relevant assessment data has been collected.

The nurse is conducting a neurovascular assessment on a postoperative knee replacement patient. Which assessment data could be considered an initial indication of neurological impairment? a) Skin directly surrounding incisional area is taut and firm to the touch b) Patient reports "pins and needles" sensation below the incision site c) Patient rates pain as 8 out of 10 comparative pain scale d) Skin temperature on affected leg is cooler distal to the incision

b) Patient reports "pins and needles" sensation below the incision site Explanation: Paresthesia may by the first symptom of changes in sensory nerves to appear. Reports of numbness, tingling or "pins and needles" sensations require further assessment both above and below the affected area. While the other options may indicate neurological impairment, they may be a result of other factors and are not usually the initial indicator of neurological impairment.

Which interventions will help minimize the risk of infection postoperatively? (Select all that apply) a) Managing pain effectively b) Assessing temperature frequently c) Maintaining hydration d) Following aseptic technique when changing incision dressings e) Implementing standard precautions

b, c, d, e Explanation: Nursing interventions to prevent infection include assessing vital signs (especially for fever); maintaining hydration; maintaining nutritional status; encouraging a diet high in proteins, carbohydrates, calories, and vitamins; using proper hand hygiene; and following aseptic technique when changing dressings at the surgical site and exit sites for tubes and drains. Dispose of soiled gloves and dressings following standard precautions. While pain management is important, it does not influence infection prevention.

In which stage of the development of an infection does the patient present the greatest risk to others? a) Incubation b) Convalescent c) Full stage d) Prodromal

d) Prodromal Explanation: A person is most infectious during the prodromal stage. Early signs and symptoms of the disease are present, but these are often vague and nonspecific. When a person is in any of the other stages, the individual does not pose as high a risk to others.