NUR 206 Final Exam with Accurate
Solutions
Medical Aspesis (clean technique) - ANSWER-measures used to reduce and prevent
the spread of pathogens (handwashing, PPE, environmental cleaning)
body's defense against infection - ANSWER-1. normal flora
2. inflammatory response
3. immune response
Surgical asepsis (sterile technique) - ANSWER-procedures to completely eliminate the
presence of pathogens from objects and areas
indirect contact transmission - ANSWER-occurs by healthcare workers hands or
contaminated equipment
chain of infection - ANSWER-- infectious agent
- reservoir (table or bed)
- portal of exit (wound drainage, GI tract)
- mode of transmission (contact)
- portal of entry (mouth or nose)
- susceptible host/vulnerable to infection (client with suppressed immune system)
noninfectious triggers - ANSWER-Physical: burns, frostbite, injury, foreign bodies,
trauma, radiation
Chemical: glucose, fatty acids, toxins, alcohol, irritants (e.g., fluoride, nickel)
Biological: damaged cells
Psychological: excitement
infectious triggers - ANSWER-viruses, bacteria, and other micro-organisms, such as
fungi.
modes of transmission of infection - ANSWER-contact, airborne, droplet
transmission based precautions - ANSWER-used for clients with a known organism and
in conjunction with standard precautions; contact, droplet, airborne, and protective
precautions
T cells - ANSWER-kill pathogen-infected cells; tell B cells to make antibodies
B cells - ANSWER-make antibodies specific for the pathogen
, antibodies - ANSWER-bind to pathogens and make them easier to kill
standard precautions - ANSWER-hand hygiene
contact precautions (2 types) - ANSWER-- direct + indirect
- common pathogens like VRE, C-diff, noro virus, draining wounds, fecal incontinence
- nurse should wear gloves and gown at minimum
droplet precautions - ANSWER-transmitted by large droplets; infection can occur within
6 to 10 ft. if no mask; influenza, pertussis, strep, pharyngitis; handwashing is important;
mask at minimum, goggles if splash is possible, and gloves if contact with secretions is
possible
airborne precautions - ANSWER-transmitted by smaller droplets that remain in the air
longer; nurse must wear N95 mask, and goggles and gloves if contact with secretions is
possible; TB, chickenpox (Varicella), measles; keep door shut and place client in a
negative pressure room that is vented to the outside or an airborne infection isolation
room
protective precautions (reverse isolation) - ANSWER-for severely immunocompromised
clients; clients with WBC below 500, stem cell transplant; client is placed in a room with
positive airflow with HEPA filtration, provide their own monitoring equipment; nurses
must wear gowns, gloves, and mask to protect the client from exposure to
microorganisms
assessment techniques - ANSWER-- inspection
- auscultation
- palpation
- percussion
protective methods of human immune system - ANSWER-- Barrier immunity; prevents
pathogens from getting into the body (mucus, skin, acidity)
- Innate immunity; immediate response to breach of a barrier (swelling and redness)
- Adaptive immunity; delayed response, but specific for each pathogen (T cells, B cells,
antibodies)
stages of infection - ANSWER-(IPADC); Incubation, prodromal, acute illness, period of
decline, period of convalescence
OLDCARTS (gathering data in an interview with a client) - ANSWER-O; onset- when
symptoms began
L; location- where symptoms occur
D; duration- how long symptoms last
C; characteristics- descriptive words (ex. Dull, sharp, radiating)
A; aggravating/alleviating factors- what effects the symptoms
Solutions
Medical Aspesis (clean technique) - ANSWER-measures used to reduce and prevent
the spread of pathogens (handwashing, PPE, environmental cleaning)
body's defense against infection - ANSWER-1. normal flora
2. inflammatory response
3. immune response
Surgical asepsis (sterile technique) - ANSWER-procedures to completely eliminate the
presence of pathogens from objects and areas
indirect contact transmission - ANSWER-occurs by healthcare workers hands or
contaminated equipment
chain of infection - ANSWER-- infectious agent
- reservoir (table or bed)
- portal of exit (wound drainage, GI tract)
- mode of transmission (contact)
- portal of entry (mouth or nose)
- susceptible host/vulnerable to infection (client with suppressed immune system)
noninfectious triggers - ANSWER-Physical: burns, frostbite, injury, foreign bodies,
trauma, radiation
Chemical: glucose, fatty acids, toxins, alcohol, irritants (e.g., fluoride, nickel)
Biological: damaged cells
Psychological: excitement
infectious triggers - ANSWER-viruses, bacteria, and other micro-organisms, such as
fungi.
modes of transmission of infection - ANSWER-contact, airborne, droplet
transmission based precautions - ANSWER-used for clients with a known organism and
in conjunction with standard precautions; contact, droplet, airborne, and protective
precautions
T cells - ANSWER-kill pathogen-infected cells; tell B cells to make antibodies
B cells - ANSWER-make antibodies specific for the pathogen
, antibodies - ANSWER-bind to pathogens and make them easier to kill
standard precautions - ANSWER-hand hygiene
contact precautions (2 types) - ANSWER-- direct + indirect
- common pathogens like VRE, C-diff, noro virus, draining wounds, fecal incontinence
- nurse should wear gloves and gown at minimum
droplet precautions - ANSWER-transmitted by large droplets; infection can occur within
6 to 10 ft. if no mask; influenza, pertussis, strep, pharyngitis; handwashing is important;
mask at minimum, goggles if splash is possible, and gloves if contact with secretions is
possible
airborne precautions - ANSWER-transmitted by smaller droplets that remain in the air
longer; nurse must wear N95 mask, and goggles and gloves if contact with secretions is
possible; TB, chickenpox (Varicella), measles; keep door shut and place client in a
negative pressure room that is vented to the outside or an airborne infection isolation
room
protective precautions (reverse isolation) - ANSWER-for severely immunocompromised
clients; clients with WBC below 500, stem cell transplant; client is placed in a room with
positive airflow with HEPA filtration, provide their own monitoring equipment; nurses
must wear gowns, gloves, and mask to protect the client from exposure to
microorganisms
assessment techniques - ANSWER-- inspection
- auscultation
- palpation
- percussion
protective methods of human immune system - ANSWER-- Barrier immunity; prevents
pathogens from getting into the body (mucus, skin, acidity)
- Innate immunity; immediate response to breach of a barrier (swelling and redness)
- Adaptive immunity; delayed response, but specific for each pathogen (T cells, B cells,
antibodies)
stages of infection - ANSWER-(IPADC); Incubation, prodromal, acute illness, period of
decline, period of convalescence
OLDCARTS (gathering data in an interview with a client) - ANSWER-O; onset- when
symptoms began
L; location- where symptoms occur
D; duration- how long symptoms last
C; characteristics- descriptive words (ex. Dull, sharp, radiating)
A; aggravating/alleviating factors- what effects the symptoms
