Skills Quiz 1

Active Immunity

Host produces antibodies in response to natural antigens (infectious microorganisms or vaccines) Active Natural Immunity- Antibodies are formed in presence of active infection in the body Duration lifelong Active Artificial Immunity- Antigens administered to stimulate antibody formation Lasts for many years Reinforced by booster

Embolus

an object that has moved from its origin, causing obstruction to circulation elsewhere

Bioterrorism

"deliberate release of viruses, bacteria, & other germs used to cause death..." (CDC) -Smallpox, anthrax, botulism, plague, viral hemorrhagic fevers, tularemia are the agents that are of highest concern with bioterrorism

Infection

Growth of microorganisms in body tissue where they are not usually found

Oral Care for the Unconscious

-Clean oral mucosa & tongue in addition to teeth -Check agency policy (2-8 hrs) -Dry mouth increase risk for infection -Chemo pts may have sores & mouth irritation -MONITOR AIRWAY AT ALL TIMES Position pt side-lying with HOB (head of bed) lowered

Diminished Cardiac Reserve

-Creates imbalance in autonomic nervous system ↑ the HR -Causes ↓ in diastolic pressure, blood flow to the heart, and the capacity of the heart to respond to increasing metabolic demands -Resulting in tachycardia with minimal exertion

Orthopenic

-Facilitates respiration by allowing maximum chest expansion -90 degrees c bed table in front to lean on

Valsalva Maneuver

-Holding your breath and straining against the closed glotis -Build up of pressure on the large veins that interferes with the return of blood flow to the heart and coronary arteries -Once you exhale the glotis opens and pressure is released causing a surge of blood to the heart -Can lead to tachycardia and arrhythmias

Physical Restraint

-Manual method or physical/mechanical device, material, or equipment attached to the patient's body -Cannot be removed easily -Restrict the clients movement

Chemical restraint

-Medications used to control socially disruptive behavior -Anxiolytics (Ativan, Xanax) -Sedatives (Amytal, Seconal) -Neuroleptics/psychotropics (Haldol,Thorazine)

Venous vasodilation and stasis

-Normal process: skeletal muscles contract and compresses muscles and blood vessels causing return to the heart, venous return to the heart occurs from the tiny valves in the leg veins= preventing pooling -In immobile person: skeletal muscles do not contract sufficiently causing atrophy; muscles can no longer assist with pumping blood back to the heart causing venous congestion and pooling

Orthostatic (postural) hypotension

-Normal process: sympathetic nervous system prevents pooling in the lower extremities maintaining the blood pressure ensuring adequate perfusion to the heart and brain -During prolonged immobility: blood pools in the lower extremities causing a drop in BP. Cerebral perfusion is compromised. -S&S: light-headed, dizzy, possibly faint

Airborne Precaution

-Private room with negative air pressure room -Wear respirator device (N95) when entering the room (known or suspected TB) -Susceptible people should not enter the room of a pt with rubeola or varicella -Limit movement of pt outside the room *pt should wear a surgical mask during transport* -Visitors report to ns before entering room -Ebola, measles, varicella, and TB

Droplet Precaution

-Private room, if unavailable, place with pt who is infected with SAME microorganism -Wear a mask within 3ft of the pt -Limit movement of pt outside the room *pt should wear a surgical mask during transport* -Diphtheria, mycoplasma pneumonia, pertussis, mumps, strep pharyngitis, pneumonia, scarlet fever

Dependent Edema

-Venous pressure ↑ , serous parts of blood are forced out of vessel into interstitial tissue, causing edema most common in parts of body positioned below the heart -Impedes blood return

Atelectasis

-Ventilation is decreased causing secretions to pool in dependent areas of bronchioles and block them -Immobility decreases the production of surfactant, which aides in keeping the alveoli open -Combination of both=collapse of a lobe or entire lung

What is the nurses role when caring for patients who have infections or are at risk for infections?

-handwashing -foam in&out

Surgical Asepsis

-sterile technique -Practices that keep an area or object free of all microorganisms (sterile) -Includes practices that destroy all microorganisms & spores

A nurse who is teaching a group of adults ages 20 to 40 years old about safety is going to ensure that which topic is a priority? 1. Automobile crashes 2. Drowning and firearms 3. Falls 4. Suicide and homicide

1. Automobile crashes

The nurse is discussing strategies with the unlicensed assistive personnel (UAP) for bathing a client with dementia. Which strategies would be appropriate for the client? Select all that apply. 1. Cover the client as much as possible. 2. Sing or talk to the client. 3. Complete the bath as quickly as possible. 4. Be organized. 5. Expect the client to protest—finish quickly.

1. Cover the client as much as possible. 2. Sing or talk to the client. 4. Be organized.

The nurse, at change-of-shift report, learns that one of the clients in his care has bilateral soft wrist restraints. The client is confused, is trying to get out of bed, and had pulled out the IV line, which was subsequently reinserted. Which action(s) by the nurse is appropriate? Select all that apply. 1. Document the behavior(s) that require continued use of the restraints. 2. Ensure that the restraints are tied to the side rails. 3. Provide range-of-motion exercises when the restraints are removed. 4. Orient the client. 5. Assess the tightness of the restraints.

1. Document the behavior(s) that require continued use of the restraints. 3. Provide range-of-motion exercises when the restraints are removed. 4. Orient the client. 5. Assess the tightness of the restraints.

Performance of activities of daily living (ADLs) and active range-of-motion (ROM) exercises can be accomplished simultaneously as illustrated by which of the following? Select all that apply. 1. Elbow flexion with eating and bathing 2. Elbow extension with shaving and eating 3. Wrist hyperextension with writing 4. Thumb ROM with eating and writing 5. Hip flexion with walking

1. Elbow flexion with eating and bathing 4. Thumb ROM with eating and writing 5. Hip flexion with walking

When caring for a single client during one shift, it is appropriate for the nurse to reuse only which of the following personal protective equipment? 1. Goggles 2. Gown 3. Surgical mask 4. Clean gloves

1. Goggles

What order do we don PPE?

1. Gown 2. gloves 3.mask 4.Eyeware

When assessing a client's gait, which does the nurse look for and encourage? 1. The spine rotates, initiating locomotion. 2. Gaze is slightly downward. 3. Toes strike the ground before the heel. 4. Arm on the same side as the swing-through foot moves forward at the same time.

1. The spine rotates, initiating locomotion.

The client wears an in-the-ear (ITE) hearing aid and because of arthritis needs someone to insert the hearing aid. Which action does the nurse teach the unlicensed assistive personnel (UAP) to do before inserting the client's hearing aid? 1. Turn the hearing aid off. 2. Soak the hearing aid in soapy solution to clean it. 3. Turn the volume all the way up. 4. Remove the batteries.

1. Turn the hearing aid off.

The nurse is planning a presentation on oral health at an intergenerational community center. Which statements will be important to include? Select all that apply. 1. Using a bottle during naps and bedtime can cause dental caries in a toddler. 2. Schedule a visit to the dentist when your child is ready to go to school. 3. It is important for parents to supervise a child's brushing of their teeth. 4. Most older adults have dentures and don't need to worry about oral care. 5. Older adults are at risk for periodontal disease.

1. Using a bottle during naps and bedtime can cause dental caries in a toddler. 3. It is important for parents to supervise a child's brushing of their teeth. 5. Older adults are at risk for periodontal disease.

Stages of Inflammatory Response

1. Vascular and cellular responses -Marked increase in blood supply called hyperemia. -Leukocytes (WBC) into interstitial space -Normal WBC 4500-11,000 2. Exudate production -Serous, purulent, sanguineous 3. Reparative phase -Regeneration -Scar tissue (cicatrix) -Granulation tissue

Which safety hazard would the nurse take into consideration when planning care for an older client? 1.Burns 2.Drowning 3.Poisoning 4.Suffocation

1.Burns

What order do we doff PPE?

1.Gloves 2.eyeware 3.gown 4.mask

The nurse determines that the instruction regarding home safety for a client had been effective when what is assessed? 1.Smoke alarm is functioning with new batteries installed 2.Scatter rugs located in the kitchen and bathroom only 3.The cord for a space heater stretches across a hallway 4.Light bulb burned out in the bathroom and living room

1.Smoke alarm is functioning with new batteries installed

A nurse is teaching a community group of school-aged parents about safety. The most important item to prioritize and explain is how to check the proper fit of 1.a bicycle helmet. 2.swimming goggles. 3.soccer shin guards. 4.baseball sliding shorts.

1.a bicycle helmet.

After teaching a client and family strategies to prevent infection prevention, which statement by the client would indicate effective learning has occurred? 1. "We will use antimicrobial soap and hot water to wash our hands at least three times per day." 2. "We must wash or peel all raw fruits and vegetables before eating." 3. "A wound or sore is not infected unless we see it draining pus." 4. "We should not share toothbrushes but it is OK to share towels and washcloths."

2. "We must wash or peel all raw fruits and vegetables before eating."

A client is being admitted to the hospital because of a seizure that occurred at his home. The client has no previous history of seizures. In planning the client's nursing care, which of the following measures is most essential at this time of admission? Select all that apply. 1. Place a padded tongue depressor at the head of the bed. 2. Pad the bed with blankets. 3. Inform the client about the importance of wearing a medical identification tag. 4. Teach the client about epilepsy. 5. Test oral suction equipment.

2. Pad the bed with blankets. 5. Test oral suction equipment.

A client with diabetes has very dry skin on her feet and lower extremities. The nurse plans to inform the client to do which of the following to maintain intact skin? 1. Soak her feet frequently. 2. Use a nonperfumed lotion. 3. Apply foot powder. 4. Avoid knee-high elastic stockings.

2. Use a nonperfumed lotion.

What intervention would help prevent falls in an older client? 1.Check vision every 5 years 2.Exercise regularly 3.Place socks on feet 4.Turn the light on after getting out of bed

2.Exercise regularly

What should the nurse do for a client who experiences a seizure? 1.Insert a tongue blade into the client's mouth 2.Loosen any clothing around the neck and chest 3.Restrain the client 4.Turn the client onto their back

2.Loosen any clothing around the neck and chest

Which nursing diagnoses would the nurse use for a client prone to falls? 1.Knowledge deficit 2.Risk for injury 3.Risk for disuse syndrome 4.Risk for suffocation

2.Risk for injury

Which statement from a client with one weak leg regarding use of crutches when using stairs indicates a need for increased teaching? 1. "Going up, the strong leg goes first, then the weaker leg with both crutches." 2. "Going down, the weaker leg goes first with both crutches, then the strong leg." 3. "The weaker leg always goes first with both crutches." 4. "A cane or single crutch may be used instead of both crutches if held on the weaker side."

3. "The weaker leg always goes first with both crutches."

A client weighs 250 pounds and needs to be transferred from the bed to a chair. Which instruction by the nurse to the unlicensed assistive personnel (UAP) is most appropriate? 1. "Using proper body mechanics will prevent you from injuring yourself." 2. "You are physically fit and at lesser risk for injury when transferring the client." 3. "Use the mechanical lift and another person to transfer the client from the bed to the chair." 4. "Use the back belt to avoid hurting your back."

3. "Use the mechanical lift and another person to transfer the client from the bed to the chair."

Medication errors can place the client at significant risk. Which practice(s) will help decrease the possibility of errors? Select all that apply. 1. Hire only competent nurses. 2. Improve the nurse's ability to multitask. 3. Establish a reporting system for "near misses." 4. Communicate effectively. 5. Create a culture of trust.

3. Establish a reporting system for "near misses." 4. Communicate effectively. 5. Create a culture of trust.

In caring for a client on contact precautions for a draining infected foot ulcer, which action should the nurse perform? 1. Wear a mask during dressing changes. 2. Provide disposable meal trays and silverware. 3. Follow standard precautions in all interactions with the client. 4. Use surgical aseptic technique for all direct contact with the client.

3. Follow standard precautions in all interactions with the client.

When planning to teach health care topics to a group of male adolescents, which topic should the nurse consider a priority? 1. Sports contribute to an adolescent's self-esteem. 2. Sunbathing and tanning beds can be dangerous. 3. Guns are the most frequently used weapon for adolescent suicide. 4. A driver's education course is mandatory for safety.

3. Guns are the most frequently used weapon for adolescent suicide.

A nurse sees smoke emerging from the suction equipment being used. Which is the greatest priority in the event of a fire? 1. Report the fire. 2. Extinguish the fire. 3. Protect the clients. 4. Contain the fire.

3. Protect the clients.

A mother and her 3-year-old live in a home built in 1932. Which NANDA nursing diagnosis is most applicable for this child? 1. Risk for Suffocation 2. Risk for Injury 3. Risk for Poisoning 4. Risk for Disuse Syndrome

3. Risk for Poisoning

A client can bathe most of her body except for the back, hands, and feet. She also can walk to and from the bathroom and dress herself when given clothing. Which functional level describes this client? 1. Totally dependent (+4) 2. Moderately dependent (+3) 3. Semidependent (+2) 4. Independent (0)

3. Semidependent (+2)

The nurse determines that a field remains sterile if which of the following conditions exist? 1. Tips of wet forceps are held upward when held in ungloved hands. 2. The field was set up 1 hour before the procedure. 3. Sterile items are 2 inches from the edge of the field. 4. The nurse reaches over the field rather than around the edges.

3. Sterile items are 2 inches from the edge of the field.

Semi-Fowler's

30 degrees

While applying sterile gloves (open method), the cuff of the first glove rolls under itself about 0.5 cm (1/4 in.). What is the best action for the nurse to take? 1. Remove the glove and start over with a new pair. 2. Wait until the second glove is in place and then unroll the cuff with the other sterile hand. 3. Ask a colleague to assist by unrolling the cuff. 4. Leave the cuff rolled under.

4. Leave the cuff rolled under.

Which nursing intervention is the highest in priority for a client at risk for falls in a hospital setting? 1. Keep all of the side rails up. 2. Review prescribed medications. 3. Complete the "get up and go" test. 4. Place the bed in the lowest position.

4. Place the bed in the lowest position.

A 75-year-old client, hospitalized with a cerebrovascular accident (stroke), becomes disoriented at times and tries to get out of bed, but is unable to ambulate without help. What is the most appropriate safety measure? 1. Restrain the client in bed. 2. Ask a family member to stay with the client. 3. Check the client every 15 minutes. 4. Use a bed exit safety monitoring device.

4. Use a bed exit safety monitoring device.

A nurse is teaching a client about active range-of-motion (ROM) exercises. The nurse then watches the client demonstrate these principles. The nurse would evaluate that teaching was successful when the client does which of the following? 1. Exercises past the point of resistance. 2. Performs each exercise one time. 3. Performs each series of exercises once a day. 4. Uses the same sequence during each exercise session.

4. Uses the same sequence during each exercise session.

A client is being transferred from an acute care facility to a long-term facility. What information should the nurse provide to the long-term facility about the client's medications? 1.Nothing, since the medications all need to be recorded at the long-term care facility. 2.Have the client's medication prescriptions filled before going to long-term facility. 3.Instruct the client to tell the nurse at the long-term care facility what the medications are prescribed. 4.Inform the nurse at the long-term care facility what medications the client is prescribed, and document that this information was provided.

4.Inform the nurse at the long-term care facility what medications the client is prescribed, and document that this information was provided.

The nursing care goal for a patient who is at risk for injury is: 1.Assess the patient's mental status. 2.Keep the client dependent on the staff for all care. 3.Make all choices for the client 4.Remain free from injury

4.Remain free from injury

Keeping the likelihood of bioterism in mind, the nurse would identify which as being the highest concern for homeland security? 1.Cancer 2.Seasonal flu 3.Tuberculosis 4.Smallpox

4.Smallpox

What would the nurse identify as a safety hazard in an infant? 1.Alcohol consumption 2.Drowning 3.Pedestrian accidents 4.Suffocation in a crib

4.Suffocation in a crib

Fowler's

45-60 degrees

Virulence

Ability of a microorganism to produce disease

Pathogenicity

Ability to produce disease Opportunistic pathogen

Breaking the chain: Portal of Exit

Avoiding talking, coughing, or sneezing over open wounds or sterile fields Covering the mouth and nose when coughing or sneezing

The patient has been diagnosed with a gastrointestinal bacteria obtained from drinking contaminated water. In the chain of infection, the water is the: a. Portal of entry b. Reservoir c. Portal of exit d. Infectious agent

B. Reservoir

A client with poor nutrition enters the hospital for treatment of a puncture wound. An appropriate nursing diagnosis would be ___________.

Because a malnourished client with a wound is less able to resist an infection, Risk for Infection is the most likely nursing diagnosis. Others may include Pain or Imbalanced Nutrition but they are less focused on the immediate health risk.

Which of the following require clean vs sterile gloves? Changing a wound dressing Taking an oral temperature Obtaining a venous blood sample Providing hygienic care Inserting a Foley catheter Removing a Foley catheter Preparing an IM injection

Changing a wound dressing-sterile Taking an oral temperature-clean Obtaining a venous blood sample-clean Providing hygienic care-clean Inserting a Foley catheter-sterile Removing a Foley catheter-clean Preparing an IM injection-clean

Breaking the chain: Reservoir

Changing dressings and bandages when soiled or wet Appropriate skin and oral hygiene Disposing of damp, soiled linens appropriately Disposing of feces and urine in appropriate receptacles Ensuring that all fluid containers are covered or capped Emptying suction and drainage bottles at end of each shift or before full or according to agency policy

Resident Flora

Collective vegetation in an area

Cleansing Bath

Complete bed bath Self-help bed bath Partial bath Bag bath Towel bath Tub bath Shower

Sepsis

Condition in which acute organ dysfunction occurs secondary to infection

Breaking the chain: Etiologic Agent

Correctly cleaning, disinfecting or sterilizing articles before use Educating clients and support persons about appropriate methods to clean, disinfect, and sterilize article

Factors influencing hygiene

Culture Religion Environment Developmental level Health & energy, motivation, depression Personal preferences Pain, acute illness, surgery

Aerobic Exercise

Demands of oxygen are greater than that used to perform the activity (aerobics, running)

Disease

Detectable alteration in normal tissue function

Evaluate

Determine whether outcomes have been achieved If outcomes were not achieved, nurse must reassess and make alterations

AM Care

Early morning care -Urinal or bedpan -Washing face and hands -Oral care Morning care (A.M.) -Usually after breakfast -Elimination -Bath or shower -Perineal care -Back massage -Oral, nail, and hair care

HS/PM Care

Elimination Washing face and hands Oral care Back massage

Chain of Infection

Etiologic agent, Reservoir, Portal of Exit, Mode of transmission, Portal of entry, Susceptible host

Risks for Newborn/Infant

Falling, suffocation, choking, burns, MVA, crib or playpen accidents, electric shock, poisoning

Risks for Older Adults

Falls, burns, pedestrian accidents, MVA

Systemic Signs of Infection

Fever Increased pulse (tachycardia) and respiratory rate if the fever high Malaise and loss of energy Anorexia and, in some situations, nausea and vomiting Enlargement and tenderness of lymph nodes that drain the area of infection

Prone

Flat on abdomen c head to one side

Supine

Flat on back

Lateral Position

Flat, Side lying, top hip and knee flexed, c leg in front of body

Therapeutic Bath

Given for physical effects Soothe irritated skin Treat a certain area (e.g. the perineum) Medication may be placed in the water Sitz, warm-water, cool-water baths

Passive (acquired) Immunity

Host receives natural (nursing mother) or artificial (from an injection of immune serum) antibodies produced from another source Passive Natural Immunity- Antibodies transferred naturally from an immune mother to baby through the placenta or in colostrum Lasts 6 months to 1 year Passive Artificial Immunity- Occurs when immune serum (antibody) from an animal or another human is injected Lasts 2 to 3 weeks

Direct Transmission

Immediate and direct transfer from person to person through biting, kissing, touching or sexual intercourse. Droplet is also a form of direct transmission (must be within 3 feet). Sneezing, coughing, spitting, talking, singing can spread organisms via droplets

Diagnosis

Inadequate primary defenses Inadequate secondary defenses Risk for infection Potential Complications of Infection Impaired physical mobility Imbalanced nutrition Acute pain Impaired social interaction Situational low self esteem

Medical Asepsis

Includes all practices to confine a specific organism to a specific area, limiting number, growth, and transmission

Nosocomial/HAI infections

Infections that originate in the hospital & Can develop during or after patient stay (Catheter-associated Urinary tract Ventilator-associated pneumonia Central IV line-associated bloodstream)

What represents the major cause of worldwide deaths?

Infectious diseases

Isotonic Exercise

Muscles shorten to produce muscle contraction and active movement (running, walking, ADLs, active ROM)

What is asepsis?

Lacking almost all microbes

Levels of Self-Care

Level 0: independent with self-care activities Level 1: equipment or devices are used to perform self-care activities independently Level 2: requires assist. or supervision to complete self-care activities Level 3: requires assist. or supervision and equipment/devices are used Level 4: completely dependent on another individual to perform self-care activities

Local Signs & Symptoms of Infection

Localized swelling Localized redness Pain or tenderness with palpation or movement Palpable heat in the infected area Loss of function of the body part affected, depending on the site and extent of involvement

Risks for Adolescents

MVA, bicycle accidents, recreational injuries, firearms, substance abuse

Planning

Maintain or restore defenses Avoid the spread of microorganisms Reduce or alleviate problems associated with the infection

Breaking the chain: Susceptible Host

Maintaining the integrity of the client's skin and mucous membranes Ensuring that the client receives a balanced diet Educating the public about the importance of immunizations

Risks for Developing Fetus

Maternal smoking, ETOH, drugs, X-rays, some pesticides

Airborne Transmission

May involve droplets or dust. Droplet nuclei, residue of evaporated droplets emitted by and infected host (TB) can remain in the air for long period of time Dust particles containing infectious agents (Clostridium difficile) can become airborne Material is transmitted by air to suitable portal of entry, usually respiratory tract

Isometric Exercise

Muscle contraction without moving the joint (sit-ups, quad exercises)

Isokinetic

Muscle contraction/tension against resistance (lifting weights)

Anaerobic Exercise

Muscles cannot get enough oxygen from the bloodstream (endurance training athletes: weightlifting, sprinting)

Assessment

Nursing History, Lab data, Physical assessment

Signs of inflammation

Pain Swelling Redness Heat Impaired function of the body part

Risks for Toddlers

Physical trauma from falls, running into objects, aspiration of small toys, cuts, MVA, burns, poisoning, drowning, electric shock

Breaking the chain: Mode of Transmission

Proper hand hygiene Instructing clients and support persons to perform hand hygiene before handling food, eating, after eliminating and after touching infectious material Wearing gloves when handling secretions and excretions Wearing gowns if there is danger of soiling clothing with body substances Placing discarded soiled materials in moisture-proof refuse bags Holding used bedpans steadily to prevent spillage Disposing of urine and feces in appropriate receptacles Initiating and implementing aseptic precautions for all clients Wearing masks and eye protection when in close contact with clients who have infections transmitted by droplets from the respiratory tract Wearing masks and eye protection when sprays of body

Sims' Position

Semi-prone halfway between the lateral and prone position

Standard precautions

Standard precautions- used in care of all hospitalized patients regardless of diagnosis or possible infection status (ex: AIDS) Tier 1:Handwashing, cough etiquette, disposal of sharps/equipment, non-sterile gown to protect against fluids Tier 2: Airborne, contact, droplet; in addition to tier 1

The Nursing Process

Systematic approach between the patient and the nurse ASSESSMENT: Systematically collect data DIAGNOSIS: Identify actual and potential problems (NANDA) PLANNING/GOALS: Develop plan of individualized care IMPLEMENT: Execute the plan EVALUATION: Evaluate the effectiveness

Universal Precautions

Techniques to be used with all clients to decrease risk of transmitting unidentified pathogens

Seizure

Temporary event that consists of an uncontrolled electrical discharge from the brain that interrupts normal brain activity

What is Self-Care?

The patient's ability to take care of themself

Functional Levels of Self-Care

Total: client CANNOT assist Moderately dependent: nurse supplies equipment, positions client, assist with putting on clothes, assists with toileting Semi-dependent: nurse provides all equipment; but client can wash some areas, dress themselves, and walk to the bathroom Independent: client can gather supplies, bathe & dress self, & use bathroom

Risks for Preschoolers

Traffic injuries, playground equipment, choking, suffocation, obstruction of airway by foreign objects, poisoning, drowning, burns, injury from people/animals

Communicable disease

Transferable to individual by direct or indirect contact

Breaking the chain: Portal of Entry

Using sterile technique for invasive procedures, when exposing open wounds or handling dressings Placing used disposable needles and syringes in puncture-resistant containers for disposal Providing all clients with own personal care items

Indirect Transmission

Vehicle-borne: any substance that serves as intermediate means to transport and introduce infectious agent to susceptible host through suitable portal of entry Vector-borne: animal or insect that serves as an intermediate means of transporting the infectious agent

Implement

Whenever possible, the nurse implements strategies to prevent infection Handwashing Universal precautions Infection control Disinfectants/sterilizing

What should the nurse do first when assisting the client to a lateral position for placement of a bedpan? a.Perform hand hygiene. b.Move the client to the side of the bed. c.Place the client's arm over the chest. d.Raise the opposite side rail.

a.Perform hand hygiene.

A client is diagnosed with a communicable disease, and must be placed in isolation. The nurse should identify which diagnosis as a priority for this client? a.Social Isolation b.Anxiety c.Acute Pain d.Imbalanced Nutrition: Less Than Body Requirements

a.Social Isolation

The most effective nursing action for controlling the spread of infection includes which of the following? a.Thorough hand cleansing b.Wearing gloves and masks when providing direct client care c.Implementing appropriate isolation precautions d.Administering broad-spectrum prophylactic antibiotics

a.Thorough hand cleansing

A client with a wound infection is placed on contact precaution based on a wound culture. When should the nurse caring for this patient don gloves? a.Upon entering the clients room b.When anticipating contact with drainage form the wound c.When determining a potential for contamination with blood or body fluids of the client d.When providing care within 3 feet of the client

a.Upon entering the clients room

Immunity that is obtained as a result of experiencing an illness is known as: a.Active natural immunity b.Passive natural immunity c.Active acquired immunity d.Passive acquired immunity

a.Active natural immunity

Which of the following is a transmission based precaution? a.Droplet b.Respiratory c.Blood d.Body fluids

a.Droplet

The client is complaining of shortness of breath. His Respirations are 28 and labored. The bed is currently in the flat position. The nurse puts the bed in which position? a.Fowler's b.Semi-Fowler's c.Trendelenburg d.Reverse Trendelenburg

a.Fowler's

A patient is incontinent of urine and stool. For which patient response should the nurse be most concerned? a.Impaired skin integrity b.Altered sexuality c.Dehydration d.Confusion

a.Impaired skin integrity

Isotonic exercises such as walking are intended to achieve which of the following? Select all that apply a.Increase muscle tone and improve circulation b.Increase BP c.Increase muscle mass and strength d.Decrease heart rate and cardiac output e.Maintain joint range of motion

a.Increase muscle tone and improve circulation c.Increase muscle mass and strength e.Maintain joint range of motion

The nurse is discussing foot care with a client who was recently diagnosed with diabetes. Which statement by the client indicates a need for further teaching? a."I am going to use a mirror to check my feet." b."I enjoy walking barefoot around the house." c."I will file my nails." d."I will increase the time that I wear new shoes each day

b."I enjoy walking barefoot around the house."

Which of the client statements indicates a client who is at risk for infection? a." I am just about five pounds overweight according to those insurance charts" b."I had my last dose of chemotherapy two weeks ago and I'm glad that's over" c."My life is pretty uneven now: I'm really busy." d."I haven't had anything more serious that a cold in the past two years."

b."I had my last dose of chemotherapy two weeks ago and I'm glad that's over"

The client is a chronic carrier of infection. To prevent the spread of the infection to other clients or health care providers, the nurse emphasizes interventions that do which of the following? a.Eliminate the reservoir b.Block the portal of exit from the reservoir c.Block the portal of entry into the host d.Decrease the susceptibility of the host

b.Block the portal of exit from the reservoir

The patient is positive for C- difficile. The nurse should institute the which of the following: a.Droplet b.Contact c.Reverse d.Airborne

b.Contact

A nurse is giving a patient a bed bath. Which nursing action is most important? a.Lower the 2 side rails on the working side of the bed b.Ensure that the bath water is at least 110'F c.Fold the washcloth like a mitt on the hand d.Raise the bed to the highest position

b.Ensure that the bath water is at least 110'F

A nurse must make the decision to give a pt a full or partial bath. On what criterion does the nurse base this decision? a.Practitioner's order for the patient's activity b.Immediate need of the patient c.Time of patient's last bath d.Patient preference

b.Immediate need of the patient

How should the nurse position a client who is complaining of dyspnea? a.High Fowler's position with two pillows behind the head b.Orthopneic position across the overbed table c.Prone position with knees flexed and arms extended d.Sims position with both legs flexed

b.Orthopneic position across the overbed table

When applying restraints in a client,, the nurse would ensure a MD's order and: a.Assess restraints every 10 minutes b.Pad bony prominences c.Secure restraint to the side rail d.Tie the restraint with a square knot

b.Pad bony prominences

In which situation can the nurse apply restraints to a patient? a.Patients wanders around the care area b.Patient is picking at the access site for IV infusion of chemotherapy c.Patient needed to use the bathroom and waited for help but didn't want to soil the bed and fell while attempting to walk to the bathroom d.Patient does not want to stay in bed but wants to sit in the lounge with others

b.Patient is picking at the access site for IV infusion of chemotherapy

After evaluating the client's chart, the nurse concludes a 65-year-old client's immunizations are current. What evidence supports this conclusion? (Select all that apply.) a.Last tetanus booster was at age 50 b.Receives a flu shot every year c.Has not received the hepatitis B vaccine d.Has not received the hepatitis A vaccine

b.Receives a flu shot every year c.Has not received the hepatitis B vaccine d.Has not received the hepatitis A vaccine

A nurse enters a patients room at the beginning of the shift. The nurse looks around the room for potential sources for infection. Which of the following options pose a potential risk for infection for this client? Select all that apply a.A bottle of saline irrigation solution which is tightly closed and a label identifying that it was opened 10 hrs earlier. b.The clients abdominal dressing has 3 different areas of moist drainage saturating the dressing and soiling the clients gown. c.An opened package of gauze sponges in present on the window sill. d.The tubing of the clients IV fluids is not labeled with the date of the last tubing change.

b.The clients abdominal dressing has 3 different areas of moist drainage saturating the dressing and soiling the clients gown. c.An opened package of gauze sponges in present on the window sill. d.The tubing of the clients IV fluids is not labeled with the date of the last tubing change.

The nurse is organizing a wellness project to educate teenagers about keeping their bodies healthy. Which information about diet and exercise should be included? a.Diet is the most important predictor of health. b.The most important factors for maintaining health are diet and activity. c.Increase in exercise is sufficient to manage most people's weight gain. d.Obese women who remain active have a low mortality rate.

b.The most important factors for maintaining health are diet and activity.

Disuse osteoporosis

bones demineralize and become spongy, deformed and are likely to fracture

The nurse is exiting an isolation room. Considering infection control protocols which would be the first action the nurse would take? a.Bag equipment and double bag it out at the door b.Remove protective gear c.Dispose of equipment inside of the room d.Wash hands

c.Dispose of equipment inside of the room

The nurse preceptor recognizes the new nurse's ability to determine patient safety risks when which behavior is observed? a.Checking patient identification once every shift b.Multitasking by gathering two patients' medications c.Disposing of used needles in a red needle container d.Raising all four side rails per family

c.Disposing of used needles in a red needle container

Signs of infection would include all of the following except: a.Swelling b.Redness c.Elevated RBC's d.Purulent drainage

c.Elevated RBC's

The client is unresponsive and requires total care by nursing staff. Which assessment does the nurse check first before providing special oral care to the client? a.Presence of pain b.Condition of the skin c.Gag reflex d.Range of motion

c.Gag reflex

When providing morning care for a pt, the nurse identifies crusty debris around the patient's eyes. What should the nurse do when cleaning the patient's eyes? a.Wear sterile gloves b.Use a tear-free baby soap c.Position the client on the same side as the eye to be cleaned d.Wash the eyes with a cotton ball from the outer canthus to the inner canthus

c.Position the client on the same side as the eye to be cleaned

The newly admitted client has contractures of both lower extremities. What nursing intervention should be included in this client's plan of care? a.Frequent position changes to reverse the contractures b.Exercises to strengthen flexor muscles c.Range of motion exercises to prevent worsening of contractures d.Weight-bearing activities to stimulate joint relaxation

c.Range of motion exercises to prevent worsening of contractures

When caring for a client with AIDS-related cancer the nurse should always use which of the following protective measures? a.Gloves, gown and mask b.Gloves c.Standard precaution d.No precautions

c.Standard precaution

The patient's abdominal dressing is described as having a moderate amount of serosanguineous drainage and a very foul odor. In planning the dressing change, it is most important for the nurse to: a.Apply extra dressings to the wound b.Use sterile gloves to remove the dirty dressing c.Wash her hands before and after the dressing change d.Change the dressing more often

c.Wash her hands before and after the dressing change

Tonic-clonic (grand mal) seizure

can effect the whole body causing loss of consciousness

Thrombophlebitis

clot loosely attached to inflamed vein wall

Thrombus

clot that can become dangerous if its breaks loose from the vein

The nurse is observing the unlicensed assistive personnel (UAP) perform perineal care for a client. Which action indicates that the nurse needs to discuss additional teaching with the UAP? a.Uses a clean portion of the washcloth for each stroke. b.Wipes from the pubis to the rectum. c.Uses clean gloves. d.Does not retract the foreskin.

d.Does not retract the foreskin.

For an infection to occur six links or steps must be present. Which of the following is not considered a link? a.Infectious agent b.Reservoir c.Portal of Entry d.Droplet transmission

d.Droplet transmission

Which of the following groups of people are most at susceptible to infection? a.Middle aged adults b.Young adults c.Young children d.Newborn infants

d.Newborn infants

The client is in surgery and will be returning to his bed via a stretcher. Which bed option reflects that the nurse appropriately planned ahead for this client? a.Open bed in low position b.Occupied bed in low position c.Closed bed in high position d.Surgical bed in high position

d.Surgical bed in high position

An individual who is more likely to acquire an infection is: a.Etiologic agent b.Vehicle c.Reservoir d.Susceptible host

d.Susceptible host

The nurse is using medical asepsis when providing client care. Which action did the nurse demonstrate? a.Administering parenteral medications b.Changing a dressing c.Performing a urinary catheterization d.Using personal protective equipment

d.Using personal protective equipment

Joint Stiffness/Pain

joints become anklyosed (permanently immobile)

Disuse Atrophy

muscles atrophy (decrease in size) losing strength and function

Contractures

permanent shortening of the muscle, limiting joint mobility and causing deformities ("foot drop")

Effects of Nosocomial infections

↑ LOS (Length of Stay) ↑ Time lost from work ↑ Costs. Results in disability, discomfort and even death