Nursing 230: FINAL EXAM UPDATED ACTUAL Questions and
CORRECT Answers
Standard Precautions (universal) Applies to all body fluids (except sweat), nonintact skin, and mucous membranes;
is done to protect everyone (staff, patient, and other patients)
What practices should be implemented with standard Hand hygiene; clean gloves when touching all body fluids, nonintact skin, and
precautions? mucous membranes; mask/eye protection/face shield when splashing occurs;
properly clean equipment; bag laundry; enable safety devices on equipment;
properly dispose of sharps
Transmission Based Precautions (Tier Two) Used in addition to standard precautions; is client specific because it is based on
the pathogen; Requires a private room (can also be referred to as isolation
precautions); three types- contact, droplet, and airborne.
Contact Precautions Used with patients who are infected by a multidrug resistant organism (MDRO);
limit movement of the patient out of the room; avoid sharing patient equipment;
PPE: gown & gloves
Infections that require contact precautions MRSA, c-diff, VRE
Droplet Precautions Used for patients with an infection that is spread by large droplet particles;
transport patient out of the room only when necessary and use mask for patient;
May have room to door open; PPE: gown, gloves, & surgical mask
Infections that require droplet precautions flu, whooping cough
Airborne precautions Used for patients who have an infection that spreads through the air; patient is
placed in neg pressure room- MUST keep door closed; PPE: gown, gloves &
respirator mask (fit tested)
Infections that require airborne precautions TB, varicella, measles, SARS
Negative Pressure Room Outer door and inner door, pressure is lower on the inside than outside, air flows
into the room rather than out
Neutropenic Precautions (reverse isolation) Used for patients with low neutrophil count; includes restricting visitors, private
room preferred, prohibiting visitors with an infection, restricting exposure to live
plants fruits and veggies, patient must wear a mask when out of room, and hand
washing for patient and staff
Medical Asepsis The use of practices to reduce the number, growth, and spread of
microorganisms
What is done to promote medical asepsis? Hand hygiene (!!), cleaning rooms and floors, changing linens, separating clean
from contaminated materials, not holding linens on you + not shaking them + not
placing on floor, biohazard bags, keep nails short + no artificial nails, clean from
least soiled to most soiled
, Surgical Asepsis The use of practices to ELIMINATE ALL microorganisms from an object or area
Promoting & Maintaining Surgical Asepsis Avoiding coughing, sneezing, or talking directly over sterile field; Touch only
sterile materials with sterile gloves; Do not reach across, above, or turn back on
sterile field; Keep patient from moving suddenly, touching sterile field, or
coughing/talking/sneezing over it
How large is the border around the sterile field that is 1 inch. Must discard any item that comes into contact with the border.
considered non-sterile?
Chain of infection Infectious agent --> reservoir --> portal of exit --> method of transmission -->
portal of entry --> susceptible host
Infectious Agent Bacteria, virus, or fungi
Reservoir Place where the microorganism is comfortable. Can be other humans, soil, water,
animals, inanimate objects (ie equipment)
Portal of Exit Respiratory (coughing, sneezing, sometimes talking), gastrointestinal (stool),
urinary (urine), breaks in skin (exposure to blood, body fluids), blood & tissue
Method of Transmission Contact, vehicles (contaminated blood, food, water), vectors (nonhuman carriers
ie mosquitoes), droplet, airborne
Portal of Entry Same as portal of entry + invasive devices like caths and IVs
Susceptible Host - what factors impact susceptibility? Intact skin & mucous membranes, normal pH levels, WBC count, age race sex and
hereditary factors, immunization, fatigue climate nutritional and general health
status, stress, invasive or indwelling devices.
How to stop an infectious agent Sterilization and antibiotics
How to stop a reservoir transmission based precautions, disposable supplies
How to stop portal of exit Gloves, covering mouth when coughing/sneezing, intact dressing
How to stop mode of transmission Pesticides, adequate refrigeration, proper precautions
How to stop portal of entry PPE, proper disposal of sharps
How to stop susceptible host Screenings and immunizations
Stages of an Infection Incubation period, Prodromal stage, Full stage of illness, and Convalescent
period
Incubation Period Organisms growing and multiplying
Prodromal Stage Vague and nonspecific signs of disease
CORRECT Answers
Standard Precautions (universal) Applies to all body fluids (except sweat), nonintact skin, and mucous membranes;
is done to protect everyone (staff, patient, and other patients)
What practices should be implemented with standard Hand hygiene; clean gloves when touching all body fluids, nonintact skin, and
precautions? mucous membranes; mask/eye protection/face shield when splashing occurs;
properly clean equipment; bag laundry; enable safety devices on equipment;
properly dispose of sharps
Transmission Based Precautions (Tier Two) Used in addition to standard precautions; is client specific because it is based on
the pathogen; Requires a private room (can also be referred to as isolation
precautions); three types- contact, droplet, and airborne.
Contact Precautions Used with patients who are infected by a multidrug resistant organism (MDRO);
limit movement of the patient out of the room; avoid sharing patient equipment;
PPE: gown & gloves
Infections that require contact precautions MRSA, c-diff, VRE
Droplet Precautions Used for patients with an infection that is spread by large droplet particles;
transport patient out of the room only when necessary and use mask for patient;
May have room to door open; PPE: gown, gloves, & surgical mask
Infections that require droplet precautions flu, whooping cough
Airborne precautions Used for patients who have an infection that spreads through the air; patient is
placed in neg pressure room- MUST keep door closed; PPE: gown, gloves &
respirator mask (fit tested)
Infections that require airborne precautions TB, varicella, measles, SARS
Negative Pressure Room Outer door and inner door, pressure is lower on the inside than outside, air flows
into the room rather than out
Neutropenic Precautions (reverse isolation) Used for patients with low neutrophil count; includes restricting visitors, private
room preferred, prohibiting visitors with an infection, restricting exposure to live
plants fruits and veggies, patient must wear a mask when out of room, and hand
washing for patient and staff
Medical Asepsis The use of practices to reduce the number, growth, and spread of
microorganisms
What is done to promote medical asepsis? Hand hygiene (!!), cleaning rooms and floors, changing linens, separating clean
from contaminated materials, not holding linens on you + not shaking them + not
placing on floor, biohazard bags, keep nails short + no artificial nails, clean from
least soiled to most soiled
, Surgical Asepsis The use of practices to ELIMINATE ALL microorganisms from an object or area
Promoting & Maintaining Surgical Asepsis Avoiding coughing, sneezing, or talking directly over sterile field; Touch only
sterile materials with sterile gloves; Do not reach across, above, or turn back on
sterile field; Keep patient from moving suddenly, touching sterile field, or
coughing/talking/sneezing over it
How large is the border around the sterile field that is 1 inch. Must discard any item that comes into contact with the border.
considered non-sterile?
Chain of infection Infectious agent --> reservoir --> portal of exit --> method of transmission -->
portal of entry --> susceptible host
Infectious Agent Bacteria, virus, or fungi
Reservoir Place where the microorganism is comfortable. Can be other humans, soil, water,
animals, inanimate objects (ie equipment)
Portal of Exit Respiratory (coughing, sneezing, sometimes talking), gastrointestinal (stool),
urinary (urine), breaks in skin (exposure to blood, body fluids), blood & tissue
Method of Transmission Contact, vehicles (contaminated blood, food, water), vectors (nonhuman carriers
ie mosquitoes), droplet, airborne
Portal of Entry Same as portal of entry + invasive devices like caths and IVs
Susceptible Host - what factors impact susceptibility? Intact skin & mucous membranes, normal pH levels, WBC count, age race sex and
hereditary factors, immunization, fatigue climate nutritional and general health
status, stress, invasive or indwelling devices.
How to stop an infectious agent Sterilization and antibiotics
How to stop a reservoir transmission based precautions, disposable supplies
How to stop portal of exit Gloves, covering mouth when coughing/sneezing, intact dressing
How to stop mode of transmission Pesticides, adequate refrigeration, proper precautions
How to stop portal of entry PPE, proper disposal of sharps
How to stop susceptible host Screenings and immunizations
Stages of an Infection Incubation period, Prodromal stage, Full stage of illness, and Convalescent
period
Incubation Period Organisms growing and multiplying
Prodromal Stage Vague and nonspecific signs of disease
