Quiz 1
Do's for communication
"Tell me more about your concerns" •Silence •Presenting reality: difficult conversations •Active Listening •Asking questions *Open-ended questions*: NO YES OR NO QUESTIONS -We can give advice "I've been here 7 years, there's always risks for a colonoscopy" •Clarifying techniques •Offering general leads/broad statements •Showing acceptance and recognition •Focusing •Giving Information •Summarizing •Offering self: "When you're not feeling good, I'll be here" •Touch: when appropriate *set boundaries/limits when needed*- You can tell an abusive patient to stop.
nursing interventions for infection
*Hand hygiene !!!!!!!!* Infection control precaution techniques, PPE Keeping patient in best possible physical condition Administer medications: Antibiotics, Antipyretics ( ASA, Acetaminophen) *Medication education: completion of treatment, no skipping!* - takes meds at same time everyday Documentation and notification Body likes BALANCE
Airborne precaution
*TUBERCULOSIS* measles, varicella, chicken pox, rubeola - * wear N 95 mask* - NEGATIVE air pressure room - patient should wear REGULAR surgical mask
Droplet precaution
- pertussis, influenza, respiratory syncital virus, rhinovirus(common cold), adenovirus, SARS, covid19, mycoplasma pneumonia, MUMPS, diptheria -don surgical mask, private room, can cohort, patient should wear mask, have patient sneeze or cough in tissue and throw it away - NUMBER 1 PPE IS MASK -if you're within 3-6 feet of pt. like taking vital signs, WEAR A MASK
Contact precautions
- shigella, scabies, clostridium difficile, norovirus, RSV, WRE, MRSA, VRE, HERPES, diarrheas' stools incontinence - Nurse should wear GLOVES and gown -Private room, cohorting with a pt. that has the same illness (consult infectious control nurse first), nurse should remove their ppe inside the clients room to prevent contamination outside -If a patient says they stopped antibiotics and got massive diarrhea (cdiff) we have to put them on contact precautions -Enteric precautions: BLEACH ONLY, Hand hygiene with soap and water
Which patient statements indicate that further teaching by the nurse is necessary regarding how to ensure protection from food contamination? Select all that apply. 1. _____" I should stuff a turkey an hour before putting it in the oven." 2. _____" I love juicy rare hamburgers with onion and tomato." 3. _____" I prefer chicken salad sandwiches with mayonnaise." 4. _____" I know to spit out food that does not taste good." 5. _____" I should defrost frozen food in the refrigerator."
1. The practice of placing stuffing inside a turkey and letting it stand at room temperature is not advisable because it promotes the multiplication of microorganisms. 2. Hamburger meat should be thoroughly cooked so that disease-producing microorganisms within the meat are destroyed.
Which condition places a patient at the greatest risk for developing an infection? 1. Implantation of a prosthetic device 2. Burns over more than 20% of the body 3. Presence of an indwelling urinary catheter 4. More than 2 puncture sites from laparoscopic surgery
2. Burns more than 20% of a person's total body surface generally are considered major burn injuries. When the skin is damaged by a burn, the underlying tissue is left unprotected and the individual is at risk for infection. The greater the extent and the deeper the depth of the burn, the higher is the risk for infection The rest are used with sterile techniques.
A young adult who had a leg amputated because of trauma says, "No one will ever choose to love a person with one leg." Which is the best response by the nurse? 1. "You are a good-looking person, and you will have no trouble meeting someone who cares." 2. "You may feel that way now, but you will feel differently as time passes." 3. "Do you feel that no one will marry you because you have one leg?" 4. "How do you see your situation at this point?"
3. is correct. This is an example of paraphrasing, which restates the patient's message in similar words. It promotes communication. 1. This negates the patient's concerns and provides false reassurance. The patient needs to focus on the "negative" before focusing on the "positive." In addition, only the future will tell if the patient meets someone who cares. 2. This is false reassurance. There is no way the nurse can ensure that this belief will change. 4. This statement is unnecessary. The patient has already stated a point of view.
A nurse is performing a focused assessment of a client's peripheral vascular system. In which of the following locations should the nurse palpate the posterior tibial pulse? A. Below the medial malleolus B. In the popliteal fossa C. In the antecubital space D. On the dorsum of the foot
A, inner circle of ankle
A nurse is conducting an admission interview with a client. Which of the following pieces of assessment information should the nurse collect during the introductory phase of the interview? A. Client's level of comfort and ability to participate in the interview B. Previous illnesses and surgeries C. Events surrounding the client's recent illness D. Sociocultural history
A.
A charge nurse is reviewing with a newly hired nurse the difference in manifestations of a localized versus a systemic infection. Which of the following are manifestations of a systemic infection? Select All A. fever B. malaise C. edema D. pain or tenderness E. increase in pulse and respiratory rate
A. B. E.
After assessing a client's radial pulses, the nurse documents "radial pulses 4+ bilaterally." The nurse should document this finding when a client's pulses have which of the following qualities? A. Bounding B. Full C. Variable D. Weak
A. bounding is correct B. is 3+ C. is rhythm not strength D. weak is 1+
A nurse is caring for a client who has a Clostridium difficile infection and is in contact isolation. Which of the following actions should the nurse take? A. Wear gloves when changing the client's gown. B. Use alcohol-based sanitizer to cleanse the hands. C. Wear a mask when assisting the client with his meal tray. D. Place the client on complete bed rest.
A. is correct B. is wrong because you should wash your hands with soap and water C. wear a mask for droplet precautions D. this can risk the patient for immobilization
Protective precautions
ALSO KNOWN AS REVERSE OR NEUTROPENIC ISOLATION Protecting patient who are immunocompromised Ex. Chemo, recent transplant Requirements: Private room PPE No flowers, fresh fruits or vegetables
Surgical asepsis
Aim is to eliminate all micro-organisms from an object or area to prevent contamination "sterile technique" (Pg. 50) Ex. Parenteral medication administration, Foley cath insertion, surgical procedures, sterile dressing changes. *** Don't forget to check for latex allergies! - Must use latex-free gloves- Schedule surgery first thing in the morning- Label O.R. as "latex free"- Clients w/latex allergy usually have an allergy to foods such as bananas, kiwis, and avocados
A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take? A. Change the topic because the client is trying to divert attention from the illness B. Encourage the client to express thoughts about death and dying C. Tell the client that religious beliefs are a personal matter D. Offer to contact the client's minister or the facility's chaplain Check Answer
B
A nurse is implementing cold therapy for a client who has an ankle sprain. Which of the following actions should the nurse take? A. Apply a cold pack to the edematous area B. Check capillary refill before applying an ice pack to the affected area C. Half-fill an ice pack with crushed ice D. Apply an ice pack for 60 min intervals Check Answer
B
A nurse on an oncology unit receives report at the beginning of her shift about 4 clients who are postoperative. Which of the following clients should the nurse see first? A. A client who is 1 day postoperative following a lobectomy for small-cell carcinoma and has a chest tube with 35 mL/hr of bright red, bloody drainage B. A client who is 2 days postoperative following a colectomy due to colorectal cancer and has an ostomy bag full of bright red, bloody drainage C. A client who is 2 days postoperative following the excision of an abdominal mass and has a portable wound suction device with 20 mL/hr of serosanguinous drainage D. A client who is 1 day postoperative following the excision of a bladder wall tumor and prostate and has continuous bladder irrigation with 300 mL/hr reddish-pink urine
B
A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse perform? A. Place the soiled linens on the chair while making the bed B. Hold the linens away from the body and clothing C. Place the linens on the floor until a linen bag is available D. Shake the clean linens to unfold
B.
A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states, "All this equipment is making me nervous." Which of the following responses should the nurse offer? A. "You won't need the equipment for very long." B. "All of this equipment can be frightening." C. "Why does the equipment bother you?" D. "Let me tell you about what each machine does."
B. is correct. This response shows that the nurse understands the feeling of the patient and will encourage the patient to open up more D. changes the subject
Infectious Agents
Bacteria: most significant and most prevalent in hospital settings - treat with antiviral or antifungal Virus: smallest of all microorganisms - vaccines, antibiotics do not work Fungi: plant-like organisms present in air, soil, and water - antifungal drugs Parasites: Protozoa, helminths, flukes, arthropods -antiparasitic drugs
When do we obtain cultures?
Before we treat with antibiotics because it can give a false result
A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection. A dietary assistant asks the nurse what precautions are necessary for entering the client's room with the lunch tray. Which of the following instructions should the nurse give to the dietary assistant? A. Don a gown before entering the room and remove it before exiting. B. Wear a mask while in the client's room. C. Don gloves when entering the room and use hand sanitizer when exiting. D. Take no special precautions unless engaging in direct contact with the client.
C. This is contact precautions, donning gloves is most important
A nurse is caring for a client who has stage 3 pressure ulcer on the heel. When preparing to irrigate the wound, which following actions should the nurse do first? A. obtain prescribed irrigation solution B. don personal protective equpiment C. check patients vital signs D. place waterproof bag under clients extremities
C. check vital signs
Who are clients at risk for infection?
Compromised immune system Poor personal hygiene and nutrition Older adults: decreased immune system (reduced inflammatory response) Poor lifestyle choices Crowded environments Recent exposure
A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit, and her ankles are edematous. Which of the following findings is another clinical manifestation of fluid volume excess? A. Sunken eyeballs B. Hypotension C. Poor skin turgor D. Bounding pulse
D
A nurse is teaching a client who is using a patient-controlled analgesia (PCA) pump to deliver morphine for pain management. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I'll limit pushing the button so I don't get an overdose." B. "If I push the button and still have pain after 2 minutes, I'll push it again." C. "I'll ask my niece to push the button when I am sleeping." D. "I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing the PCA button."
D. B is not correct because it should be 6-8 minutes
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 because its more specific
A nurse manager is providing teaching to a group of newly licensed nurses about ways that clients acquire health care-associated infections (HAIs). Which of the following routes of infection should the manager identify as an iatrogenic HAI? A. Infection acquired from improper hand hygiene B. Infection acquired by drug resistance C. Infection acquired by inappropriate waste disposal D. Infection acquired from a diagnostic procedure
D. is a result from diagnostic or therapeutic
What can lead to a falsely high and falsely low blood pressure readings?
Falsely high: the blood pressure cuff is too tight, too small for pt., after exercise, smoking or NOT SUPPORTING CLIENTS ARM Falsely low: cuff that is too large or applying it too loosely
Nursing Interventions for changes in temperature
Hyperthermia •Elevated temperature "fever" •Cultures/find source •Labs/diagnostics •Fluids and rest •Cooling blanket •Provide antipyretics •Prevent shivering Oral hygiene hypothermia •< 95 •Warming blanket •Warmed fluids •Cardiac monitoring
Medical and Surgical asepsis
Medical asepsis Aim is to reduce the number, growth, and spread of micro-organisms "clean technique" Ex. Oral medication administration, NG Tubes, providing personal hygiene, common tasks Surgical asepsis Aim is to eliminate all micro-organisms from an object or area to prevent contamination "sterile technique" (Pg. 50) Ex. Parenteral medication administration, Foley cath insertion, surgical procedures, sterile dressing changes. *** Don't forget to check for latex allergies!* - Must use latex-free gloves - Schedule surgery first thing in the morning - Label O.R. as "latex free" - Clients w/latex allergy usually have an allergy to foods such as bananas, kiwis, and avocados
Don'ts of communication
Never ask "why" False reassurance Don't change the subject Don't minimize their feelings Argue Stereotype Give personal opinions Offering sympathy
Two categories of defense mechanisms against infection
Nonspecific innate -Guards against infections by keeping them out of the body - Intact skin, mucous membrane, inflammatory response, stomach acid, Acts fast Specific adaptive immunity -Tracks down those pathogens that managed to get through the body's nonspecific defenses. -Produce antibodies through T lymphocytes, B lymphocytes
How to communicate with special needs? Patient Can't Speak Clearly (aphasia), Patient Visually Impaired, Patient Cognitively Impaired, Patient Unresponsive, Patient Hearing Impaired, Patient Doesn't Speak English
Patient Can't Speak Clearly (aphasia) Photos, Diagrams, pen and paper, writing boards Patient Visually Impaired Large print materials, braille, speak normal Patient Cognitively Impaired Speak clearly, simple questions, minimize noise, stay focused, patience Patient Unresponsive Verbal, Touch Patient Hearing Impaired Close facing patient, Speak slowly, encourage use of hearing aids, do not cover mouth, written material, sign language Patient Doesn't Speak English Translator, written material **when using translator speak facing patient
SOLER
S- sit facing patient O- open posture L- lean forward E- eye contact R- relax
Systemic vs. Local
Systemic (All over body) •Fever/chills •Tachycardia •Tachypnea •Fatigue •N/V/D •ABD cramping •Enlarged lymph nodes (collect waste) (won't have fatigue in an ear) Local Erythema Warmth Edema Pain/tenderness @ site Drainage
Adult Vital Signs: •Temperature (T), HR, Blood pressure (BP), Respiration (R), O2 sat, Pulse (P), Pain (often included as fifth sign)
Temp: 96.8F-100.4F HR: 60-100/min Pulse: 60-100 BP: 120/80 Resp: 12-20/min O2 sat: 95-100%
Other Common Nosocomial Infections, MDRI's
These are super infections that are resistant to antibiotics •MRSA (methicillin-resistant Staphylococcus aureus) •VRSA (vancomycin-resistant Staphylococcus aureus) •Cdiff (clostridium difficile) - contact with stool •Sepsis: systemic (all over body, now its in bloodstream) - we are worried about the misuse of antibiotics that kills both good and bad cells and the infection will become powerful. Potent antibiotics DESTROY THE KIDNEY AND LIVER
Patient Doesn't Speak English
Translator, written material **when using translator speak facing patient
Four Categories Responsible for Majority of Hospital-Acquired Infections (HAI's)
Urinary tract infections (Cauti's) - foley catheters are sterile Surgical site infections Bloodstream infections (ex. clabsi's) Pneumonia-ventilated associated
Laboratory tests that indicate an infection
WBCS greater than 10,000 (normal 5,000-10,000) ESR: >20 = infection, inflammation Left shift = increase in neutrophils. Immature WBC's
Transpersonal
addresses spiritual needs and provides interventions to meet these needs
ISBAR
background is needed PRIOR
Chain of infection
causative agent: risk of infection by microorganism ex) bacteria Reservoir: human, plant, animal, faucet. Where is harbors and grows Portal of exit: same as entry, ears, nose, mouth. GI tract, respiratory tract, GU tract, blood Mode of transmission: direct contact, indirect contact, airborne, droplet Portal of entry: ears, nose, mouth. GI tract, respiratory tract, GU tract, blood Susceptible host: impairment of the body's natural defenses
Therapeutic Communication
client-centered communication directed at achieving client goals. Purposeful, Planned, and Goal directed Determine Needs Older Adults vs. Children, Sociocultural Background Components: *Active listening* trust, empathy, nonjudgmental, caring attitude
Potential causes for a clients increase in blood pressure?
nicotine, anxiety, fear, obesity, Age, gender, race Circadian rhythm Food intake Exercise Weight Emotional state/stress Body position Drugs/medications Results- Size of cuff
Factors Affecting Blood Pressure
•Age, gender, race •Circadian rhythm •Food intake •Exercise •Weight •Emotional state/stress •Body position •Drugs/medications Results- Size of cuff
Rate and Depth of Breathing
•Changes in response to tissue demands •Controlled by respiratory centers in the medulla and pons •Activated by impulses from chemoreceptors •Increase in carbon dioxide is the most powerful respiratory stimulant
Diagnostic procedures for infection
•Cultures: urine, blood, sputum, Stool, or draining cultures •Culture and sensitivity •When do we obtain cultures? - OBTAIN CULTURES BEFORE ANTIBIOTICS! because we might get false results We look at cultures and SENSITIVITY to see what antibiotics work •XRAY, CT, MRI, Biopsy
Aspirin (ASA)
•Drug Class: nsaid's •Use: mild to mod. Pain, fever •Adverse effects: Bleeding Salicylism/tinnitis •Reye's syndrome • patient education: Report bleeding. Do not use if hx bleeding disorder. Report ringing in ear 19 and under do not take if viral infection
acetaminophen
•Drug class: acetaminophen •Use: mild to mod. Pain, fever •Adverse effects: Liver toxicity Hypertension (particularly women) •Patient education: Do no exceed 4g/day (adults) Routine bp checks Avoid alcohol
Laboratory and Diagnostics for infections
•Elevated white blood cell count (WBC): >__10,000 (normal 5,000-10,000) •Elevated erythrocyte sedimentation rate (ESR): > 20 mm/hr •Cultures: urine, blood, sputum, Stool, or draining cultures - the culture tells us what agent it is. ex) pt. is coughing secretions, we check sputum to see if it's TB or COVID. •Culture and sensitivity - sensitivity let's us know what antibiotics work •XRAY, CT, MRI, Biopsy
Stages of Infection
•Incubation period: organisms growing and multiplying. No symptoms. Ex) groggy, weak •Prodromal stage: person is most infectious, vague and nonspecific signs of disease - cough, sniffles •Full stage of illness: presence of specific signs and symptoms of disease •Convalescent period: recovery from the infection - body system is compromised because it just recovered from battle, patients still need to take it easy, STILL vulnerable
Opioid antagonist
•Naloxone (Narcan) •Use: Reversal of opioid effects, overdose. Treats bradypnea. •Adverse effects: Increased respiratory rate, blood pressure, heart rate •Patient education: Contraindicated for opioid dependence USE NARCAN IS RESPIRATORY IS LESS THAN 8 or if PT. IS DIFFICULT TO AROUSE
A nurse working in a clinic is assessing patients of a variety of ages. People within which age group should the nurse particularly assess for subtle signs and symptoms of subclinical infections? 1. Children of school age 2. Older adults 3. Adolescents 4. Infants
2. Infections are more difficult to identify in the older adult because the signs and symptoms are not as acute and obvious as in other age groups, as a result of the decline in all body systems related to aging
A nurse is concerned about a patient's ability to withstand exposure to pathogens. Which blood component should the nurse monitor? 1. Platelets 2. Hemoglobin 3. Neutrophils 4. Erythrocytes
3. Neutrophils, the most numerous leukocytes (white blood cells), are a primary defense against infection because they ingest and destroy microorganisms (phagocytosis). When the leukocyte count is low, it indicates a compromised ability to fight infection.
Which does the nurse determine is a secondary line of defense against infection? 1. Mucous membrane of the respiratory tract 2. Urinary tract environment 3. Integumentary system 4. Immune response
4 is correct. The immune response is a specific, secondary line of defense against pathogenic microorganisms. The production of antibodies to neutralize and eliminate pathogens and their toxins (immune response) is activated when phagocytes fail to destroy invading microorganisms completely. The primary, nonspecific defenses (e.g., anatomical, mechanical, chemical, and inflammatory) work in harmony with the secondary defense (immune response) to defend the body from pathogenic microorganisms. The rest are primary defenses
A nurse is caring for the following group of patients with infections. Which infection is classified as a hospital-acquired infection? 1. Respiratory infection contracted from a visitor 2. Vaginal canal infection in a postmenopausal woman 3. Urinary tract infection in a patient who is sedentary 4. Wound infection caused by unwashed hands of a caregiver
4. is correct. A hospital-acquired infection directly results from a diagnostic or therapeutic procedure. When a caregiver does not wash his/her hands, thereby transmitting a pathogen that causes a wound infection, the result is an iatrogenic infection
Which patient condition identified by a nurse is unrelated to infection? 1. Catabolism 2. Hyperglycemia 3. Ketones in the urine 4. Decreased metabolic activity
4. is correct. Metabolic activity increases, not decreases, with an infection as the body mounts a defense to fight invading pathogenic microorganisms. 1. Catabolism, the destructive phase of metabolism with its resultant release of energy, is related to infection. 2. Serum glucose is increased (hyperglycemia) in the presence of an infection because of the release of glucocorticoids in the general adaptation syndrome. 3. The presence of ketones in the urine, a sign that the body is using fat as a source of energy, is related to infection because of the associated increased need for calories for fighting the infection.
A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning how to self-inject insulin. Which of the following statements should the nurse make? A. "Tell me what I can do to help you overcome your fear of giving yourself injections." B. "Your provider will not be pleased that you refuse to give yourself insulin injections." C. "It's okay. I'm sure your partner will be able to learn how to give you the insulin injections." D. "You won't be able to go home unless you learn to give yourself insulin injections."
A is the most therapeutic, clarifies, and offers self
A nurse is caring for a client who has severe acute respiratory syndrome SARS. The nurse knows that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? 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 Endemic is not necessary
A nurse is collecting a specimen for culture from a client's infected wound. Which of the following actions should the nurse perform? A. Wear sterile gloves when collecting the specimen B. Cleanse the wound with 0.9% sodium chloride irrigation C. Allow the collection swab to absorb old exudate D. Rotate the collection swab over the edges of the wound Check Answer
B. A is not correct because it should be clean gloves C. pooled drianage can collect microoorganisms causing the infection D. swab back and forth
A nurse is caring for a patient who reports dizziness when standing up. The clients blood pressure after lying supine for 15 minutes is 136/86 mm Hg in the left arm. Which of the following would indicate the client is experiencing orthostatic hypotension? A. BP 128/84 left arm after sitting for 2 mins B. 120/78 left arm immediately after sitting C. 114/72 left arm immediately after standing D. 124/80 left arm after standing for 3 mins
C. If the patients SYSTOLIC pressure DECREASES BY MORE THAN 20 or their DIASTOLIC by more then 10 after changing positions, then they have ORTHO HYPOTENSIONS
A nurse is performing an admission assessment for a client. Which of the following responses by the nurse reflects the communication technique of clarifying? A. "Now that we talked about your medications, let's talk about your pain" B. "Are you having other symptoms?" C. "It sounds like your pain is intermittent" D. "It seems as though you have had a really rough time these past few weeks"
C. is correct D. shows empathy not clarifying
A nurse is caring for a client who has had a cough for 3 weeks and is beginning to cough up blood. The client has manifestations of which of the following conditions? A. allergic reaction B. Ringworm C. Systemic lupus erythematosus D. tuberculosis
D. tuberculosis
Interpersonal
communication between two people
Public communication
communication to, within, or between large groups of people. Using this type of communication, many nurses teach, give community presentations, or write about nursing or health care topics.
Intrapersonal
communication with oneself; within an individual. Thinking without verbalizing. Helps nurses assess clients and situations and think critically about them before communicating.
Small Group
communication within a group of people working toward a mutual goal (ex. nursing groups)
Respirations Pulmonary ventilation, Diffusion, Perfusion
•Pulmonary ventilation: movement of air in and out of lungs -Inhalation: breathing in -Exhalation: breathing out •Diffusion -Exchange of oxygen and carbon dioxide between the alveoli of lungs and circulating blood -Measure with Pulse oximetry •Perfusion -Exchange of oxygen and carbon dioxide between circulating blood and tissue cells -Measure with pulse oximetry
Opioid Adverse Effects
•Sedation •Resp. Depression •Orthostatic hypotension •Urinary retention •N/V •Constipation
Opioid Agonist
•morphine, fentanyl (Sublimaze), meperidine (Demerol), methadone (Dolophine) •Use: mod. To severe Pain •Adverse effects: Respiratory depression (bradypnea) Sedation/dizziness constipation (give stool softener) • patient education: Take drug only when needed Do not take prior to driving or activities requiring mental alertness Increase fluid and fiber intake
Which primary defenses protect the body from infection? Select all that apply. 1. _____Tears in the eyes 2. _____Healthy intact skin 3. _____Cilia of respiratory passages 4. _____Alkalinity of gastric secretions 5. _____Bile in the gastrointestinal system 6. _____Moist environment of the epidermis
1. Tears flush the eyes of microorganisms and debris and are a primary defense that protects the body from infection. 2. Healthy, intact skin prevents entry of many pathogens. In addition, the normal flora of the skin hinders growth of disease-causing microorganisms that settle on the skin. 3. Cilia line the nasal passages, sinuses, trachea, and larger bronchi and are tiny hair-like cells that sweep microorganisms up from the lower airways. These microorganisms are then expelled from the body by coughing and sneezing. 4. Acidity, not alkalinity, of gastric secretions is a primary defense mechanism that protects the body from infection. 5. Bile helps emulsify fats; it does not protect the body from infection. 6. A dry, not moist, epidermis is a primary defense mechanism that protects the body from infection.
Which should the nurse do to interrupt the transmission link in the chain of infection? 1. Wash the hands before providing care to a patient. 2. Position a commode next to a patient's bed. 3. Provide education about a balanced diet. 4. Change a dressing when it is soiled.
1. This is an example of controlling the mode of transmission. Direct transmission of microorganisms from one person to another is interrupted when microorganisms are removed from the skin surface by hand washing. Hand washing is part of hand hygiene, which also includes nail care, skin lubrication, and wearing of minimal jewelry in a health-care environment. Hand hygiene should be performed before and after patient care and whenever contamination has occurred.
A nurse educator is evaluating whether a new staff nurse understands the relationship between a fever and an infection. Which statement by the new staff nurse indicates an understanding of this relationship? 1. "Phagocytic cells release pyrogens that stimulate the hypothalamus." 2. "Leukocyte migration precipitates the infl ammatory response." 3. "Erythema increases the fl ow of blood throughout the body." 4. "Pain activates the sympathetic nervous system."
1. is correct. Microorganisms or endotoxins stimulate phagocytic cells, which release pyrogens that stimulate the hypothalamic thermoregulatory center, causing fever. 2. Leukocyte migration does not precipitate the inflammatory response but is a phase of the inflammatory response. White blood cells reach a wound within a few hours after the injury to ingest bacteria and clean a wound of debris through the process of phagocytosis. 3. Erythema does not increase the flow of blood throughout the body. Increased blood flow to a localized area causes erythema. 4. Pain does not cause an increase in body temperature directly.
Which interviewing skill is used when the nurse says, "You mentioned before that you are having a problem with your colostomy." 1. Focusing 2. Clarifying 3. Paraphrasing 4. Acknowledging
1. is correct. This example of focusing helps the patient explore a topic of importance. The nurse selects one topic for further discussion from among several topics presented by the patient. 2. This is not an example of clarifying, which lets the patient know that a message was unclear and seeks specifi c information to make the message clearer. 3. This is not an example of paraphrasing, which is restating the patient's message in similar words. 4. This is not an example of acknowledging, which is providing nonjudgmental recognition for a contribution to the conversation, a change in behavior, or an effort by the patient.
A patient is admitted to the hospital with cirrhosis of the liver caused by long-term alcohol abuse. Which is the best response by the nurse when the patient says, "I really don't believe that my drinking a couple of beers a day has anything to do with my liver problem"? 1. "You find it hard to believe that beer can hurt the liver." 2. "How long is it that you have been drinking several beers a day?" 3. "Each beer is equivalent to one shot of liquor so it's just as damaging to the liver as hard liquor." 4. "Do you believe that beer is not harmful even though research shows that it is just as bad for you as hard liquor?"
1. is correct. This is an example of paraphrasing. It repeats the content in the patient's message in similar words to provide feedback to let the patient know whether the message was understood and to prompt further communication. 2. This response does not address the content or emotional theme of the patient's statement. In addition, this probing question may be a barrier to further communication. 3. Although factual, this response is confrontational. This nurse's statement may put the patient on the defensive and inhibit further communication. 4. This assertive, confronting, judgmental response may put the patient on the defensive and cut off communication.
Which is the nurse doing when using the interviewing technique of attentive listening ? 1. Identifying the patient's concerns and exploring them with why questions 2. Determining the content and feeling of the patient's message 3. Employing silence to encourage the patient to talk 4. Using nonverbal skills to display interest
2. is correct. Attentive listening is the active use of all the senses to comprehend and appreciate the patient's verbal and nonverbal thoughts and feelings. 1. "Why" statements are direct questions that tend to put the patient on the defensive and cut off communication 3. Silence is a passive interaction. Silence allows the patient time for quiet contemplation of what has been discussed. 4. When talking with patients, verbal and nonverbal cues are used to indicate care and concern, which promote communication.
Which stage of an interview establishes the relationship between the nurse and the patient? 1. Preinteraction stage 2. Orientation stage 3. Examining stage 4. Working stage
2. is correct. The purposes of the orientation stage of an interview are to establish rapport and orient the interviewee. A established through a process of creating goodwill and trust. The orientation stage focuses on explaining the purpose and nature of the interview and what is expected of the patient 1. The preinteraction stage occurs before the nurse meets the patient. During this stage the nurse gathers information about the patient. 3. There is no stage called the examining stage in an interview. Examining takes place during a physical assessment, when specific skills are used to collect data systematically to identify health problems. 4. This is not the purpose of the working stage. In the working stage, also called the body stage, of an interview patients communicate how they think, feel, know, and perceive in response to questions by the nurse
A patient who has had a number of postoperative complications appears upset and agitated, yet withdrawn. Which is the most appropriate statement by the nurse? 1. "You seem distressed. Tell me why you are upset." 2. "You've been having a pretty rough time of it since surgery." 3. "It's not uncommon to have complications after the kind of surgery that you had." 4. "I'm not sure that I know everything that has been happening. Tell me what has happened to you since surgery."
2. is correct. This is an example of the therapeutic interviewing skill of an open-ended statement. It demonstrates that the nurse recognizes what the patient is going through, and the statement encourages free verbalization by the patient. At the very least it demonstrates caring and concern. 1. The first part of this statement uses the therapeutic interviewing technique of reflection, which identifies the underlying feelings of the patient and is appropriate. However, the second half of the statement is asking for an explanation, which is inappropriate. Patients often interpret "why" questions as accusations, which can cause resentment and mistrust and should be avoided. 3. This statement minimizes the patient's feelings and is not supportive. 4. This statement will not inspire confidence in the nurse. Nurses should know what is happening if care is to be comprehensive and patient centered.
A patient has a wound infection. Which local human responses should the nurse expect to identify? Select all that apply. 1. _____Neutropenia 2. _____Malaise 3. _____Edema 4. _____Fever 5. _____Pain
3. Chemical mediators increase the permeability of small blood vessels, thereby causing fl uid to move into the interstitial compartment, with resulting local edema. 5. Pain is caused by localized edema that puts pressure on the surrounding nerves; this is associated with the local adaptation syndrome. rest is systemic. Leukocytosis (a lot of wbc) is systemic and localized, neutropenia is a decrease is wbc and does not indicate infection
A nurse is caring for a patient with a high fever secondary to septicemia. The primary health-care provider orders a cooling blanket (hypothermia blanket). Through which mechanism does the hypothermia blanket achieve heat loss? 1. Radiation 2. Convection 3. Conduction 4. Evaporation
3. is correct. Conduction is the transfer of heat from a warm object (skin) to a cooler object (hypothermia blanket) during direct contact.
A nurse is caring for a client who has a temperature of 38.7°C (101.7°F). Which of the following actions should the nurse take? A. Apply an alcohol-water solution to the client's skin B. Keep the client's bed linens dry C. Apply ice packs to the groin D. Limit the client's fluid intake to 1183 mL (40 oz) of fluid per day Check Answer
B. A, C are not recommended because it can cause shivering. D. we want to give the patient fluids
A nurse is reviewing the medical records for a group of clients. Which of the following clients should the nurse identify as being at risk for tachycardia? A. 24 year old long distance runner who starts walking in the hallway B. 38 year old client who has a fever due to an infection C. 51 year old who received an opioid anaglesic 2 hours ago D. 66 year old who has heart failure
B. A fever is a risk factor for tachycardia. An increase in temperature can increase pulse, respiratory rates, and bp.
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 interventions should the nurse include? select all that apply A. place the client in a room with negative air pressure B. wear a mask when providing care within 3ft of the patient C. place a surgical mask on the client if transportation to another department in unavoidable D. use sterile gloves when handling soiled linens E. wear a gown when performing care that might result in contamination from secretions
B. C. E. D. use non-sterile gloves
A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse perform first? A. Open all sterile supplies and solutions. B. Stabilize the tracheostomy tube. C. Put on sterile gloves. D. Perform hand hygiene.
D. perform hand hygiene
Orthostatic (Postural) Hypotension
Patient will have orthostatic hypotension if their systolic pressure decreases by 20 or their diastolic decreases by 10 with a 10-20% increase in HR when changing positions. Take in supine position, have pt. sit up for 3-5 mins, then stand for 3-5 mins, and take bp while standing. Interventions: Assess & monitor BP, dizziness, weakness, fainting, ambulate with assistance, sit @ edge of bed for 1 min. before standing, avoid sudden changes in position. Pt risk for falls
