PCC 1 exam 1 part 1

What is medical asepsis?

"clean technique" -reduces number of pathogens -prevents the transfer of organisms ***HANDWASHING is number 1 ** clean gloves is also key

Normal body temperature:

98.6 F or close to 99 rectal may be about 0.7-1 degree higher exercise can change temperature

The nurse is assessing a patient with a heart rate of 55. Which of the following patients would be most likely to have a pulse rate of 55? A 70-year-old telephone salesman who is dehydrated A 20-year-old runner who had surgery 4 days ago for a fractured leg A 67-year-old who presented with an exacerbation of his COPD An infant who has a temperature of 100.1° F

A 20-year-old runner who had surgery 4 days ago for a fractured leg

The nurse pours a sterile liquid into a container. Which action made by the nurse is appropriate?

Pouring a small amount in a disposable cap before pouring in the container

what do you typically wear for droplet precautions?

Surgical masks within 3 feet

The nurse is instructed to clean a patient's infected surgical wound. How should the nurse apply antiseptic on the wound? Select all that apply.

Wipe around the edge of the wound first. Clean outward from the wound.

hypertension

abnormally high BP

standard precautions:

assume blood and body fluid of ANY patient should be or could be infectious

The best sterilizer in a home setting is -----

boiling water

bradycardia:

heart rate less than 50 beats/min

hyperthermia:

overheated body or fever

What is the portal of exit of the influenza virus?

respiratory tract

Counting respirations:

should be relaxed, silent, regular 12-20 per minute is normal count for 30 seconds if abnormal count for 60

What is patient centered care?

recognizing the patients source of control. Providing compassionate care based on the respect of their preferences, values, and needs

recording weight:

record in Kilograms take shoes off and heavy clothing aim for the same time each day

what do you wear for and airborne infection isolation patient?

respirator also a negative pressure isolation room is required

Which patient has the highest susceptibility to infection? bronchitis multiple sclerosis diabetes mellitus second degree burns

second degree burns

taking tympanic membrane temperature:

sense infrared emissions of the ear drum quick and noninvasive make sure to not occlude the canal low risk of cross contamination

The neutrophils are 20%. The patient becomes worried and asks the nurse about it. What is the probable reason for a reduced neutrophil count?

sepsis

What noncritical item used requires a surface disinfection?

stethoscope

Vital signs:

temperature weight height respirations pulse blood pressure

Taking Oral temperature:

the sublingual pocket has a rich blood supply Always wait 15 minutes after eating/ drinking to take temp and 2 minutes after smoking

gloves are used when:

touching blood, body fluids, secretions, excretions, contaminated items; for touching mucus membranes and non intact skin

How to take BP:

use a stethoscope and sphygmomanometer patient should be relaxed sitting or lying with arm at heart level Find the brachial pulse put cuff about 2.5 cm above that pulse pump up cuff about 20-30 mm Hg above where you stop feeling pulse

When is medical asepsis used?

used in admin. of -medications -tube feedings -enemas -daily hygiene

How to take pulse:

using 3 fingers palpate the radial pulse if regular: count for 30 seconds and must. by 2 irregular: count for 60 seconds

hypothermia:

usually caused by prolonged exposure to cold

The nurse suspects the exit of an infectious organism through a purulent skin discharge. What would be the components of this discharge?

white blood cells

when is surgical asepsis used?

-invasive procedures -insertion of catheters -inserting IV's -applying sterile dressing -suctioning tracheobronchial airways

Assessing pain:

0-10 scale when did it start? how long does it last? does anything make it better or worse? what does it feel like? nonverbal cues

5 moments for hand washing

1. before patient contact 2. after patient contact 3. before aseptic task 4. after contact with any patient surroundings 5. after body fluid exposure risk

applying PPE

1. hand hygiene 2. apply gown 3.apply mask 4 put on eye equipment 5. put on gloves

Principles of Surgical Asepsis:

1. only sterile objects may be placed on sterile field 2. below the waste or out of eye contact is contaminated 3. becomes contaminated by exposure to air 4. breaks sterile field when comes into contact with wet or contaminated surfaces 5. fluid flows in the direction of gravity 6. edges of the sterile field are contaminated

The nurse understands that cleaning involves removing organic and inorganic soil from objects and surfaces. Arrange the steps involved in cleaning in the correct order.

1.Rinse contaminated objects or articles with cold running water to remove organic material. 2.Wash the object with soap and warm water, and rinse again thoroughly. 3.Use a brush to remove dirt or material in grooves or seams. 4.Rinse the object in warm water. 5.Dry the object and prepare it for disinfection or sterilization. 6.Clean and dry the brush, gloves, and sink used to clean the equipment.

acute pain

6 months or less

chronic pain

6 months or more

what is a normal pulse?

60-100 beats is normal may increase during exercise, fever, or anxiety

Aging adults for Vitals:

80-90s weight decreases shorter less likely to have fever pulse may be irregular BP increases shallow respirations

tachycardia:

95 beats/min or over

The nurse isolates the patient in a room with positive airflow and the patient is instructed to use a mask when he or she is out of their room. What condition may the patient have?Laryngeal tuberculosis Streptococcal pharyngitis Disseminated varicella zoster Allogeneic hematopoietic stem cell transplants

Allogeneic hematopoietic stem cell transplants

A patient is crying and says, "Please get me something to relieve this pain." What should the nurse do next? -Verify that the patient has an order for pain medications and administer order as directed. -Assess the level of pain and ask patient what usually works for his or her pain, administer pain medication as needed, then reassess pain level. -Assess the level of pain and give medications according to pain level, and then reassess pain. -Reposition the patient, then reassess the pain after intervention.

Assess the level of pain and ask patient what usually works for his or her pain, administer pain medication as needed, then reassess pain level.

facts about blood pressure:

BP is the force of blood pushing against the side of the vessel wall Systolic (higher number) over Diastolic (resting phase) 120/80 is normal hypertension risks: age, weight, exercise, stress

Which microorganism causes gas gangrene?

Clostridium perfringens

what do you typically wear for contact precautions?

Gown and gloves for contact with patient or environment of care (e.g., medical equipment, environmental surfaces) -In some instances these are required for entering patient's environment

What is evidence based practice?

Integrate the best current evidence with clinical experience and patient/family preferences for optimal health

Which microorganism exits through a man's urethral meatus during sexual contact?

Neisseria gonorrhea exits through a man's urethral meatus or a woman's vaginal canal during sexual contact

A registered nurse teaches a nursing student about normal flora. Which statement of the nursing student indicates a need for further learning?

Normal flora may cause disease when residing in their usual area of the body.

Which task cannot be delegated to nursing assistive personnel?

Preparation of a sterile field

A registered nurse teaches a student nurse about how age influences infection prevention and control. Which statements made by the nursing student indicate the need for further learning? Select all that apply.

"The immune system declines as the child grows." "An infant's immune system produces a large amount of immunoglobulins."

What is surgical asepsis?

"sterile technique" -eliminates ALL pathogens -prevents contamination of an open wound -isolates operative area from unsterile environments -maintains sterile field

A patient is suspected of having malaria. Which mode of transmission spreads malaria?

Vector transmission, such as infection by a mosquito, is responsible for malaria

The nurse is reassessing a patient's pain level after pain medication administration following a pain level of 9/10. The patient states that his pain level is now a 3/10. What should the nurse do next? Verify orders for medications and offer more pain medication, if appropriate. Continue to assess patient's pain level. Document the pain level in the chart. There is no need for action, because the patient's pain is manageable.

Verify orders for medications and offer more pain medication, if appropriate.

Significant elevation in blood pressure measurements from one day to the next could be attributed to: (select all that apply) a decrease in cuff size. an increase in cuff size. new onset of pain or anxiety.

a decrease in cuff size. new onset of pain or anxiety.

hypotension

abnormally low BP

Which instrument used by the nurse requires surface disinfection? Endoscope Cardiac catheter Urinary catheter blood pressure cuff

bp cuff

Factors that may increase BP:

cardia output vascular resistance volume elasticity of arterial walls

orthostatic vitals

check BP lying then standing

orthostatic hypotension:

drop in BP of more than 20 mm Hg or increase in pulse of 20 BPM

masks, goggles, or face shields are used when:

during patient care activities likely to generate splashes or sprays of blood, body fluids, secretions, or excretions

gowns are used when:

during procedures and patient care activities when contact of clothing/ exposed skin with blood/ blood fluids, secretions or excretions are anticipated

Which symptoms indicate the presence of a SYSTEMIC infection? Select all that apply.

fatigue malaise

While performing hand hygiene, ------ should be removed.

finger rings Wearing rings increases the risk for infection because the skin underneath the rings carries a high bacterial load

False BP readings occur when:

if the cuff is too big you will have a low reading cuff is too small= false high deflating too quickly = false low deflating too slow= false high diastolic

sinus arrhythmia

irregularity found in pulse in children or young adults

Taking rectal temperature:

most accurate route closest to the core as you can get Insert a lubricated rectal probe cover on an electric thermometer 2-3 cm into the adult rectum , toward umbilicus