ATI PREP 1
A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (Select all that apply.) A. Planning and evaluating control and prevention strategies B. Determining public health priorities C. Ensuring proper medical treatment D. Identifying endemic disease E. Monitoring for common-source outbreaks
A. Planning and evaluating control and prevention strategies B. Determining public health priorities C. Ensuring proper medical treatment E. Monitoring for common-source outbreaks
a nurse is caring for a client who has a history of falls. which of the following actions is the nurses priority A. complete fall-risk assessment B. educate client and family about fall risks C. eliminate safety hazards from clients environment D. make sure the client uses assistive devices
A. complete fall-risk assessment
a nurse manager is reviewing guidelines to preventing injury with staff nurses. which of the following instructions should they include (select all that apply) A. request assistance when repositioning a client B. avoid twisting your spine or bending at waist C. keep knees slightly lower than hips when sitting for long periods of time D. use smooth movements when lifting and moving clients E. take a break from repetitive movements every 2-3 hours to flex and stretch your joints and muscles
A. request assistance when repositioning a client B. avoid twisting your spine or bending at waist D. use smooth movements when lifting and moving clients
Infant and toddlers safety risks
Aspiration (keep small objects out of reach) Suffocation (put on back to sleep, keep bags out of reach) Poisoning (keep houseplants and cleaning agents out of reach and meds locked up) Falls (keep crib and play pen rails up) Motor vehicle injury (rear facing car seat until 2 years old) Burns (test and temp of formula and bath water, place pots on back of stove, cover outlets)
a nurse is providing discharge instructions to a client who has a prescription for O2 use at home. which of the following info should the nurse include about at home O2 safety (select all that apply) A. family members who smoke must be at least 10 ft from patient when O2 is in use B. nail polish should not be used near a client who is receiving O2 C. "no smoking" sign put on front door D. cotton bedding and clothing should be replaced with items made from wool E. fire extinguished should be readily available
B. nail polish should not be used near a client who is receiving O2 C. "no smoking" sign put on front door E. fire extinguished should be readily available
a nurse educator is discussing the faculty protocol in the event of a tornado with the staff. which of the following should the nurse include in the instructions (select all that apply) A. open doors to client rooms B. place blankets over clients who are confined to beds C. move beds away from windows D. draw shades and close drapes E. instruct ambulatory clients to hallways to return to their rooms
B. place blankets over clients who are confined to beds C. move beds away from windows D. draw shades and close drapes
Basic first aid
Bleeding (apply pressure) Fractures and splinting (assess for swelling, deformity, skin integrity, temperature, distal pulses, mobility and apply a splint to immobilize fracture) Sprains (use RICE to manage sprains, refrain from weight bearing, apply ice, elevate) Heat stroke (body temp greater than 104, hot dry skin, hypotension, tachypnea, tachycardia, anxiety, confusion, seizures, coma, no sweat, remove clothing, place ice on arteries, don't allow to shiver) Frostnip and frostbite (earlobes, nose, fingers, toes, warm in a warm bath) Burns (cover client and maintain NPO status, elevate extremities, administer fluids) Altitude-related illness (client can become hypoxic in high altitudes. headache, nausea, vomiting, dyspnea, anorexia. give oxygen)
A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects may the nurse touch without breaching sterile technique? (Select all that apply.) A. A bottle containing a sterile solution B. The edge of the sterile drape at the base of the field C. The inner wrapping of an item on the sterile field D. An irrigation syringe on the sterile field E. One gloved hand with the other gloved hand
C. The inner wrapping of an item on the sterile field D. An irrigation syringe on the sterile field E. One gloved hand with the other gloved hand
an occupational health nurse is caring for an employee who was exposed to an unknown chemical, resulting in a chemical burn. which of the following interventions should the nurse include in the plan of care A. irrigate the affected area with running water B. wash the affected area with antibacterial soap C. brush the chemical off the skin and clothing D. leave the clothing in place until emergency personnel arrive
C. brush the chemical off the skin and clothing
a nurse is caring for multiple clients during a mass casualty event. which of the following clients is priority A. client who received crush injuries to the chest and abdomen and is expected to die B. client who has a 4-inch laceration to the head C. client who has partial-thickness and full-thickness burns to his face, neck, and chest D. client who has a fractured tibia and fibula
C. client who has partial-thickness and full-thickness burns to his face, neck, and chest
a nurse on a med-surge unit is informed that a mass casualty event occurred in the community and that it is necessary to discharge stable clients to make beds available for injury victims. who should the nurse recommend for discharge (select all that apply)chug A. client who is dehydrated and receiving IV fluid and electrolytes B. client who has a NG tube to treat a small bowel infection C. client who is scheduled for elective surgery D. client who has chronic hypertension and BP is 135/85 E. client who has acute appendicitis and is scheduled for appendectomy
C. client who is scheduled for elective surgery D. client who has chronic hypertension and BP is 135/85
a nurse is caring for a client who fell at a nursing home. the client is oriented to person, place, and time and can follow directions. which of the following actions should the nurse take to decrease the risk of another fall (select all that apply) A. place belt restraint on the client when he is sitting on the bedside commode B. keep bed in lowest position with all side rails up C. make sure clients call light is within reach D. proved nonskid footwear E. complete fall-risk assessment
C. make sure clients call light is within reach D. proved nonskid footwear E. complete fall-risk assessment
a nurse observes smoke coming from under the door of the staffs lounge. which of the following actions is the nurses priority A. extinguish the fire B. activate the alarm C. move the clients who are nearby D. close all open doors on the unit
C. move the clients who are nearby
When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. When preparing the sterile field, it is important that the nurse A. keep the sterile field at least 6 ft away from the client's bedside. B. instruct the client to refrain from coughing and sneezing during the dressing change. C. place a mask on the client to limit the spread of micro-organisms into the surgical wound. D. keep a box of facial tissues nearby for the client to use during the dressing change.
C. place a mask on the client to limit the spread of micro-organisms into the surgical wound.
nurse is completing discharge instructions for a client who has COPD. nurse should identify that the client understands the orthopenic position when she states that she will do which of the following when she has difficulty breathing at night A. lie on her back with her head and shoulders on pillow B. lie flat on stomach with head to one side C. sit on side of bed and rest arms over pillows on top of bedside table D. lie on side with weight on hip and shoulder with arm flexed in front
C. sit on side of bed and rest arms over pillows on top of bedside table
Classes for fire extinguisher
Class A: for combustibles such as paper, wood, upholstery, rags, trash Class B: for flammable liquids and gas fires Class C: for electrical fires
Categories of triage during mass casualty events
Class I: Emergent category (highest priority given to clients with life-threatening injury but highest possibility of survival) Class II: Urgent category (second highest priority to clients with major injuries that aren't yet life-threatening and can wait 45-60 min for treatment) Class III: Nonurgent category (next highest priority to clients with minor injuries that are not life-threatening and do not need immediate attention) Class IV: Expectant category (lowest priority to clients who are going to die)
Semi-fowlers
Client is supine with head of bed elevated 15 to 45 degrees (usually 30 degrees) This position prevents regurgitation of enteral feeding and aspiration by clients who have difficulty swallowing Also promotes lung expansion for clients who have dyspnea or are receiving mechanical ventilation
Prone
Client lies flat on his abdomen and chest with his head to one side and his back in correct alignment Promotes drainage from the mouth after throat or oral surgery but inhibits chest expansion For short-term use only Helps prevent hip flexion contractors following a lower extremity amputation
Lateral or side-lying
Client lies on side with most of his weight on the dependent hip and shoulder and his arms in flexion in front of his body. Pillow under his head and neck, his upper arms, and his legs and thighs to maintain body alignment. Good sleeping position, but client needs turning regularly to prevent pressure ulcers. A 30 degree lateral position is essential for clients at risk for pressure ulcers
High-fowler's
Client lies supine with head of bed elevated 60 to 90 degrees Promotes lung expansion by lowering the diaphragm and helps relieve severe dyspnea Helps prevent aspiration during meals
Modified trendelenburg
Client remains flat with his legs above the level of his heart Helps prevent and treat hypovolemia and facilitates venous return
Orthopneic
Client sits in bed or at bedside with a pillow on overbed table, which is across clients lap. He rests his arms on the overbed table. Allows for chest expansion and is especially beneficial for clients who have COPD
CPR
Combination of basic interventions designed to sustain oxygen and circulation to vital organs until more advanced interventions can be initiated Circulation (chest compressions) and oxygenation (ventilations) in the absence of cardiac output Component of BLS
a charge nurse is assigning rooms for the clients to be admitted to the unit. to prevent falls, which of the following clients should be assigned to rooms closest to the nursing station A. a middle adult who is postop following a laparoscopic cholecystectomy B. a middle adult who requires telemetry for a possible myocardial infarction C. young adult who is postop following an open reduction internal fixation of the ankle D. an older adult who is postop following a below-the-knee amputation
D. an older adult who is postop following a below-the-knee amputation
a home health nurse is discussing the dangers of carbon monoxide poisoning with a client. which of the following info should the nurse include in her counseling A. carbon monoxide has a distinct odor B. water heaters should be inspected every 5 years C. the lungs are damaged from carbon monoxide inhalation D. carbon monoxide binds with hemoglobin in the body
D. carbon monoxide binds with hemoglobin in the body
nurse is caring for client who is sitting in a chair and asks to return to bed. which of the following actions is the nurses priority right now A. obtain a walker for the client to use to transfer back to bed B. call for additional staff to assist C. use transfer belt and assist D. determine clients ability to help with transfer
D. determine clients ability to help with transfer
a security officer is reviewing actions to take in the event of a bomb threat by phone to a group of nurses. which of the following statements by a nurse indicates understanding A. i will get the caller off the phone as soon as possible so i can alert the staff B. i will begin evacuating client using the elevators C. i will not ask questions and just let the caller talk D. i will listen for background noises
D. i will listen for background noises
a nurse educator is conducting a parenting class for new parents of infants, which of the following statements made by a participant indicates understanding of the instructions A. i will set my water heater at 103F B. once my baby can sit up he should be safe in the bathtub C. i will place my baby on his stomach to sleep D. once my infant starts to push up, i will remove the mobile from over the crib
D. once my infant starts to push up, i will remove the mobile from over the crib
Contact
Direct physical contact (person to person) Indirect contact (with a vehicle of transmission, inanimate object, water, food, blood) Fecal-oral transmission (handling food after using restroom and not washing hands)
Preschoolers and school-age children safety risks
Drowning (supervision near pools) Motor vehicle injury (use booster seats for children under 4 feet and less than 40 lbs, teach child safety about road) Begin sex education for school-age children Firearms (keep guns unloaded and locked up) Play injury (not to run with stuff in mouth, avoid strangers) Burns (reduce water heater setting to no higher than 120 degrees) Poison (teach about hazards of alcohol, cigarettes, and drugs)
Joint commission
Emergency preparedness management standards for various types of healthcare facilities Notifying and assigning personnel Managing space and supplies Isolating and decontaminating radioactive or chemical agents Evacuating Performing triage of incoming clients Managing clients during emergency Interacting with family and media Identifying backup resources Crisis support Conducting two drills per year
List four key elements that a home safety plan should include
Keep emergency numbers near the phone for prompt use Ensure that the number and placement of fire extinguishers and smoke alarms are adequate, they are operable, and everyone can operate them Have exit plan for fires that everyone practices If clients clothing or skin is on fire the client should stop, drop, and roll Review oxygen safety measures
List the steps involved in putting on a pair of sterile gloves
Use non dominant hand to pick up dominant hand glove by grasping the folded bottom edge of the cuff and lifting it away from wrapper Pull dominant hand into glove With sterile dominant glove place fingers inside cuff of non dominant glove and lift it up and away and insert non dominant hand into it Adjust the fingers
List four key elements of proper lifting techniques
Use the major muscle groups to prevent back strain, and tighten abdominal muscles to increase support to back muscles Distribute weight between large muscles of arms and legs to decrease strain When lifting from the floor, flex your hips, knees, and back. Bring object to thigh level, bend your knees and keep back straight. Stand up while holding object as close as possible to body. Use assistive devices whenever possible and seek assistance whenever you need it
Airborne precautions
Used to protect against droplet infections smaller than 5 mcg (measles, varicella, tuberculosis) private room masks and respiratory protection devices USE N95 if tuberculosis Negative pressure airflow Full face protection
Reverse trendelenburg
Entire bed is tilted with foot of bed lower than head of bed Promotes gastric emptying and prevents esophageal reflux
Trendelenburg
Entire bed is tilted with head of bed lower than foot of bed Facilitates postural drainage and venous return
Describe at least 6 nursing responsibilities when caring fora client in either seclusion or restraints
Explain the need for the restraints Ask the client to sign a consent form Review the instructions Assess skin integrity Offer food and fluid Provide a means for hygiene and elimination Monitor vital signs Pad bony prominences Use a quick release knot Make sure restraints are loose enough for ROM Remove or replace restraints frequently Conduct an ongoing evaluation
Plague
Fever, headache, weakness, pneumonia with SOB, chest pain, cough, bloody sputum chills Prevent with contact precautions and droplet precautions Treat with streptomycin/gentamicin or tetracycline/doxycycline
Criteria for when clients can be safely discharged
First: ambulatory clients requiring minimal care Second: Clients requiring assistance Last: Clients who are unstable
Smallpox
High fever, fatigue, rash, headache, chills, vomiting, delirium Prevent with vaccine and contact and airborne precautions Treat with supportive care
Must wash hands
*With sanitizer or soap* Before and after client contact After removing gloves *With soap and water* When hands are visibly soiled After contact with body fluids Before eating After using restroom
Wash hands for at least
15 seconds
Ergonomics
A science that focuses on the factors or qualities in an object's design or use that contribute to comfort, safety, efficiency, and ease of use. Body mechanics and body alignment
Antipyretics
Acetominophen and aspirin Monitor fever Document temp fluctuations
Adolescents safety risks
Motor vehicle injury (seat belts, ensure they can drive well) Burns (sunblock)
Fire extinguisher
P: Pull the pin A: Aim at the base of the fire S: Squeeze the handle S: Sweep the extinguisher from side to side
List the six links in the chain of infection that must be present for an infection to occur
Causative agent Reservoir Portal of exit Mode of transmission Portal of entry Susceptible host
Sims' or semi prone
Client is on his side halfway between lateral and prone, with weight on anterior ileum, humerus, and clavicle. Lower arm behind while upper arm is in front. Both legs in flexion but upper leg flexed at greater angle than lower leg Comfortable sleeping position and promotes oral drainage
Supine or dorsal recumbent
Client lies on his back with his head and shoulders elevated on a pillow and his forearms on pillows or at his side. A foot support prevents foot drop and maintains proper alignment
Fowler's
Client lies supine with head of bed elevated 45 to 60 degrees Useful during procedures such as nasogastric tube insertion and suctioning Allows better chest expansion and ventilation and better dependent drainage after abdominal surgeries
Inhalation anthrax
Fever, cough, SOB, muscle aches, mild chest pain, meningitis, shock Prevent with anthrax vaccine, ciprofloxacin and doxycycline Treat with one or two antibiotics such as vancomycin, penicillin and anthrax antitoxin
Security plan
Include preventative, protective, and response measures designed for identified security needs Admission of potentially dangerous individuals, vandalism, infant abduction, and information theft
a nurse is caring for a client who is receiving enteral tube feedings due to dysphagia. which of the following bed positions should the nurse use A. supine B. semi-fowlers C. semi-prone D. Trendelenburg
B. semi-fowlers
RICE
Rest Ice Compression Elevation
Types of exudate
Serous (clear) Sanguineous (contains red blood cells) Purulent (contains leukocytes and bacteria)
Cutaneous anthrax
Starts as itchy lesion, develops into vesicular lesion that later becomes necrotic with formation of black eschar, fever, chills Prevent with anthrax vaccine Treat with ciprofloxacin and doxycycline
Body alignment
Keeps the center of gravity stable, which promotes comfort and reduces strain on the muscles
Inflammatory response
Localizes the area of microbial invasion and prevents its spread Phagocytic cells (neutrophils, eosinophils, macrophages) the complement system, and interferons are involved Nonspecific immunity
Internal emergencies
Loss of electric power or potable water, severe damage or casualties within the facility related to fire, weather, explosion, or terrorist attack.
Pathogens
Micro-organisms or microbes that cause infections Bacteria (staph, e coli, tuberculosis) Viruses (organisms that use the host's genetic machinery to reproduce, HIV, herpes, hepatitis) Fungi (molds and yeasts, candida, aspergillus) Prions (protein particles, creutzfeldt jakob disease) Parasites (protozoa, malaria, toxoplasmosis, and helminths, worms, flukes)
Chain of infection
*Causative agent* (bacteria, virus, fungi, prion, parasite) *Reservoir* (human, animal, food, water, soil) *Portal of exit* (leaving the host, respiratory tract-droplet or airborne, GI tract, GU tract, skin/mucous membranes, blood/body fluids, transplacental) *Mode of transmission* (Contact, droplet, airborne, vector borne) *Portal of entry* (entering host) *Susceptible host* (compromised defense mechanisms leave host more susceptible to infections)
Stages of an infection
*Incubation* (interval between the pathogen entering body and first symptom) *Prodromal* (interval from onset of general symptoms to more distinct symptoms. pathogen is multiplying) *Illness* (interval when symptoms specific to infection occur) *Convalescence* (interval when acute symptoms disappear. total recovery could take days to months)
Stages of inflammatory response
1. local infection (redness, warmth, edema, pain, tenderness) 2. Microbes are killed. (fluid containing dead tissues cells and WBC's accumulates and exudate appears at site of infection, exudate leaves body by draining into lymph system) 3. Damaged tissue replaced by scar tissue
Herpes zoster
A common viral infection that erupts years after exposure to chickenpox and invades a specific nerve tract Shingles Painful and debilitating A rash that is erythematous, vesicular, pustular, or crusting
Disaster
A mass casualty or intra-facility event that at least temporarily overwhelms or interrupts the normal flow of services of a hospital
Primary survey
A rapid assessment of life-threatening conditions No longer than 60 seconds Standard precautions to prevent contamination with body fluids (gloves, gown, eye protection, masks, shoe covers)
Seizure
A sudden surge of electrical activity in the brain. Can occur at any time due to epilepsy or fever Partial seizures (focal seizures) are due to electrical surges in one part of the brain Generalized seizures involve the entire brain Status epilepticus (prolonged seizure) is a medical emergency
Carbon monoxide
A very dangerous gas because it binds with hemoglobin and ultimately reduces the oxygen supplied to the tissues in the body Symptoms of poisoning include nausea, vomiting, headache, weakness, and unconsciousness Gas-burning furnaces, water heaters, and appliances should be checked annually It has no odor!!
a nurse educator is presenting a module on basic first aid for newly licensed home health nurses. the nurse educator evaluates the teaching as effective when the newly licensed nurse states that the client who has heat stroke will have which of the following A. hypotension B. bradycardia C. clammy skin D. bradypnea
A. hypotension
ABCDE principle
A: Airway/cervical spine (patent airway, protect cervical spine if head or neck trauma is suspected) B: Breathing (Assess for presence and effectiveness of breathing) C: Circulation D: Disability (clients level of consciousness E: Exposure (to heat and cold)
Specific adaptive immunity
Allows the body to make antibodies in response to a foreign organism (antigen) This reaction directs against an identifiable micro-organism *Active*: antibodies are produced in response to an antigen Requires time to react to antigen Provides permanent immunity Involves B- and T-lymphocytes Produces specific antibodies against specific antigens (immunoglobulins, IgA, IgD, IgE, IgG, IgM)
A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (Select all that apply.) A. The provider drops a sterile instrument onto the near side of the sterile field. B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. C. The procedure is delayed 1 hr because the provider receives an emergency call. D. The nurse turns to speak to someone who enters through the door behind the nurse. E. The client's hand brushes against the outer edge of the sterile field.
B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. C. The procedure is delayed 1 hr because the provider receives an emergency call. D. The nurse turns to speak to someone who enters through the door behind the nurse.
A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing handwashing? (Select all that apply.) A. Apply 3 to 5 mL of liquid soap to dry hands. B. Wash the hands with soap and water for at least 15 seconds. C. Rinse the hands with hot water. D. Use a clean paper towel to turn off hand faucets. E. Allow the hands to air dry after washing.
B. Wash the hands with soap and water for at least 15 seconds. D. Use a clean paper towel to turn off hand faucets.
A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following should the nurse include in the plan of care? (Select all that apply.) A. Place the client in a room that has negative air pressure of at least six exchanges per hour. B. Wear a mask when providing care within 3 ft of the client. C. Place a surgical mask on the client if transportation to another department is unavoidable. D. Use sterile gloves when handling soiled linens. E. Wear a gown when performing care that may result in contamination from secretions.
B. Wear a mask when providing care within 3 ft of the client. C. Place a surgical mask on the client if transportation to another department is unavoidable. E. Wear a gown when performing care that may result in contamination from secretions.
a nurse manager is reviewing with nurses on the unit the care of a client who has had a seizure. which of the following statements by a nurse requires further instruction A. i will place the client on his side B. i will go to the nurses station for assistance C. i will administer his meds D. i will prepare to insert an airway
B. i will go to the nurses station for assistance
a home health nurse is discussing the dangers of food poisoning with a client. which of the following info should the nurse include (select all that apply) A. most food poisoning is caused by a virus B. immunocompromised individuals are at risk for complications from poisoning C. clients who are at high risk should eat or drink only pasteurized dairy D. healthy individuals usually recover from illness in a few weeks E. handling raw and fresh food separately can prevent food poisoning
B. immunocompromised individuals are at risk for complications from poisoning C. clients who are at high risk should eat or drink only pasteurized dairy E. handling raw and fresh food separately can prevent food poisoning
a nurse educator is reviewing the proper body mechanics during employee orientation. which of the following statements should the nurse identify as an indication that an attendee understands the teaching (select all that apply) A. my line of gravity should fall outside my base of support B. the lower my center of gravity the more stability i have C. to broaden my base of support i should spread my feet apart D. when i lift an object i should hold it as close to my body as possible E. when pulling an object i should move my front foot forward
B. the lower my center of gravity the more stability i have C. to broaden my base of support i should spread my feet apart D. when i lift an object i should hold it as close to my body as possible
External emergencies
Hurricanes, floods, volcano eruptions, earthquakes, disease epidemics, industrial accidents, chemical plant explosions
Bioterrorism
The dissemination of harmful toxins, bacteria, viruses, and pathogens for the purpose of causing illness or death Anthrax, various, clostridium botulism, yersinia pestis
Food poisoning
The major cause of illness in the US Most caused by bacteria Escherichia coli, listeria monocytogenes, and salmonella Hand hygiene, meat and fish cooked to correct temp, handling raw and fresh food separately, and refrigerating perishable items can prevent it Check expiration dates and clean fruits and vegetables
Passive smoking
The unintentional inhalation of tobacco smoke Can cause bronchitis, pneumonia, and middle ear infections in children
Body mechanics
The use of muscles to maintain balance, posture, and body alignment when performing a physical ask. Reduces risk of injury Whenever possible, use mechanical lift devices to lift and transfer clients
Lifting
Use major muscle groups to prevent back strain and tighten abdominal muscles to increase support to back muscles Arms and legs
Asepsis
the absence of illness-producing micro-organisms Hand hygiene* Medical asepsis (use to precise practices to reduce number, growth, and spread of microorganisms) Surgical asepsis (use of precise practices to eliminate all microorganisms from an object or area to prevent contamination)
Oxygen safety measures
No smoking sign Ensure electrical equipment is in good repair and well grounded Replace bedding that can generate static electricity (wool, nylon, synthetics) with cotton Keep flammable materials (heating oil and nail polish remover) away from client and oxygen Have fire extinguisher readily available
Droplet precautions
Protect against droplets larger than 5 mcg and travel 3-6 ft from client (streptococcal pharyngitis or pneumonia, influenza type B, scarlet fever, rubella, pertussis, mumps, mycoplasma pneumonia, meningococcal pneumonia and sepsis, pneumonic plague) Private room or room with someone who has same disease Their own equipment Masks
Contact precautions
Protect within 3 ft of client against direct client (shigella, wound, impetigo, scabies, herpes simplex) Private room or room with someone who has same disease Gloves and gowns
Fire response
R: Rescue and protect client in close proximity to the fire by moving them to a safer location A: Alarm- activate the alarm system and report the fire C: Contain/confine the fire by closing doors and windows and turning off oxygen E: Extinguish
Native immunity (nonspecific innate)
Restricts entry or immediately responds to a foreign organism (antigen) through the activation of phagocytic cells, complement, and inflammation. This occurs with all micro-organisms, regardless of previous exposure *Passive*: antibodies are produced by an external source Temporary immunity; does not have memory of past exposures Intact skin, the body's first line of defense Mucous membranes, secretions, enzymes, phagocytic cells, and protective proteins Inflammatory response with phagocytic cells, the complement system, and interferons localize the invasion and prevent its spread
Tularemia
Sudden fever, chills, headache, diarrhea, muscle aches, joint pain, dry cough, weakness Prevent with vaccine Treat with streptomycin or gentamicin
Virulence
The ability of a pathogen to invade and injure a host
Center of gravity
The center of a mass Lower your center of gravity by bending the hips and knees and spreading feet apart It results in stability and balance When body is in upright position, the center of gravity is the pelvis, when an individual moves, the center of gravity shifts
A nurse educator is reviewing with a newly hired nurse the difference in clinical manifestations of a localized versus a systemic infection. The nurse indicates understanding when she states that which of the following are clinical manifestations of a systemic infection? (Select all that apply.) A. Fever B. Malaise C. Edema D. Pain or tenderness E. Increase in pulse and respiratory rate
A. Fever B. Malaise E. Increase in pulse and respiratory rate
Ebola, yellow fever, viral hemorrhagic fevers
Fatigue, kidney failure, elevated temp, nausea, vomiting, diarrhea, internal and external bleeding, shock Prevent with vaccine and barrier protection from infected person No cure
Botulism
Difficulty swallowing, double vision, slurred speech, weakness, nausea, vomiting, cramps, difficulty breathing Prevent and treat with airway management, antitoxin, elimination of toxin
A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crustings. Which of the following should the nurse suspect? A. Allergic reaction B. Ringworm C. Systemic lupus erythematosus D. Herpes zoster
D. Herpes zoster
A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection? A. Prodromal B. Incubation C. Convalescence D. Illness
D. Illness
A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? A. The flap closest to the body B. The right side flap C. The left side flap D. The flap farthest from the body
D. The flap farthest from the body
