NR 224 Final Exam (Answered) 341
Questions and Correct Answers, 100%
Correct, Latest 2024/2025.
Who is at increased risk of infection?
-elderly
-infants
-immobility
-autoimmune
-malnourished
-immunocompromised
-transplant
-chemo
-HIV
-steroids
Body's Natural Defenses
-skin
-mucus membranes
-saliva/tears/sweat
-inflammation
-GI/GU (flushing)
-immune system
-respiratory tract (cilia/cough)
What is the nurses role in infection control?
assess, education, use proper precautions
Chain of Infection
1. Infectious Agent
2. Reservoir
3. Portal of Exit
4. Mode of Transmission
5.Portal of Entry
6. Susceptible Host
*goal is to break the chain
Infectious Agent
-bacteria, virus, protozoa, fungus
-resident flora: bacteria that is already present
,-transient flora: attaches to the skin -> causes infection
-virulence: strength
Reservoir
-H2O, body fluids, animals, insects, food, people
-needs proper environment (temp, pH, light, O2)
Portal of Exit
-body fluids, respiratory tract, GI, GU, mucus membranes, skin, blood, transplacental
Mode of Transmission
-direct contact: fecal-oral, shaking hands (contact precautions
-indirect contact: objects, needles (contact precautions)
-droplet: 3ft travel, bigger (droplet precautions)
-airborne: smaller, evaporated droplets (airborne precautions)
Tier 1
standard precautions: hand-washing, gloves, needle safety, proper disposal of biohazard
Tier 2
contact: gown and gloves (MRSA, VRE)
modified contact: soap, water, bleach based products (CDIFF)
droplet: mask, gloves, gown (flu, pneumonia)
airborne: negative air flow, hepa filter, antiroom, N95 mask, gown, gloves (TB, measles, varicella,
meningitis)
Port of Entry
-preferably same as exit
Susceptible Host
-ability to get infection, vaccinations make host lest susceptible
Surgical Asepsis
-hands above waist (even when throwing away trash)
-eliminate all pathogens
-some dressing changes
-catheterizations
-surgical procedures
-not needed for NG tube insertions since the cavity is not sterile
-dont put things on bedside table!
Nursing responsibilities with skin
,-assessment
-prevention of skin breakdown (reassess every-time you get pt.)
-important since when a pressure ulcer happens - WE pay for it, not medicare/medicaid
High risk for skin breakdown
-elderly, obesity, neuro issues, same as list for increased risk for infection
Braden Scale
checks for risk of skin breakdown, the more points, the less likely for skin breakdown, 12 or less = high
risk
Pressure Ulcers
-capillary displacement -> lack of blood flow = lack of O2 -> ischemia -> necrosis
Factors for Pressure Ulcers
-intensity: intense pressure or light pressure over a long time
-duration
-tolerance: how strong is skin, health, malnourished?
Stage I Pressure Ulcer
-non-blanchable erythema
Stage II Pressure Ulcer
-partial thickness loss of dermis
-shallow open ulcer with red pink wound bed
-open or intact blister
, Stage III Pressure Ulcer
-full thickness skin loss
-subcutaneous fat may be visible
-tunneling or undermining
Stage IV Pressure Ulcer
-full thickness tissue loss
-visible muscle, bone, tendon
-undermining
Describing a Wound
-measure
-look at wound bed itself
-describe (yellow)
-tunneling/undermining (describe like a clock, cm)
-drainage (purulent, serous, serosanguinous (pink tinge), sanguinous (bleeding)), amount of drainage
(scant, small, moderate, excessive amount)
-odor
Skin Shear
-friction (a force that occurs in a direction to oppose movement), force exerted against the skin while the
skin remains stationary
Skin Tear
tear in skin from something
Prevention of Skin Breakdown
-nutrition, change brief consistently (acidity), barrier cream
Types of Wound Healing
Questions and Correct Answers, 100%
Correct, Latest 2024/2025.
Who is at increased risk of infection?
-elderly
-infants
-immobility
-autoimmune
-malnourished
-immunocompromised
-transplant
-chemo
-HIV
-steroids
Body's Natural Defenses
-skin
-mucus membranes
-saliva/tears/sweat
-inflammation
-GI/GU (flushing)
-immune system
-respiratory tract (cilia/cough)
What is the nurses role in infection control?
assess, education, use proper precautions
Chain of Infection
1. Infectious Agent
2. Reservoir
3. Portal of Exit
4. Mode of Transmission
5.Portal of Entry
6. Susceptible Host
*goal is to break the chain
Infectious Agent
-bacteria, virus, protozoa, fungus
-resident flora: bacteria that is already present
,-transient flora: attaches to the skin -> causes infection
-virulence: strength
Reservoir
-H2O, body fluids, animals, insects, food, people
-needs proper environment (temp, pH, light, O2)
Portal of Exit
-body fluids, respiratory tract, GI, GU, mucus membranes, skin, blood, transplacental
Mode of Transmission
-direct contact: fecal-oral, shaking hands (contact precautions
-indirect contact: objects, needles (contact precautions)
-droplet: 3ft travel, bigger (droplet precautions)
-airborne: smaller, evaporated droplets (airborne precautions)
Tier 1
standard precautions: hand-washing, gloves, needle safety, proper disposal of biohazard
Tier 2
contact: gown and gloves (MRSA, VRE)
modified contact: soap, water, bleach based products (CDIFF)
droplet: mask, gloves, gown (flu, pneumonia)
airborne: negative air flow, hepa filter, antiroom, N95 mask, gown, gloves (TB, measles, varicella,
meningitis)
Port of Entry
-preferably same as exit
Susceptible Host
-ability to get infection, vaccinations make host lest susceptible
Surgical Asepsis
-hands above waist (even when throwing away trash)
-eliminate all pathogens
-some dressing changes
-catheterizations
-surgical procedures
-not needed for NG tube insertions since the cavity is not sterile
-dont put things on bedside table!
Nursing responsibilities with skin
,-assessment
-prevention of skin breakdown (reassess every-time you get pt.)
-important since when a pressure ulcer happens - WE pay for it, not medicare/medicaid
High risk for skin breakdown
-elderly, obesity, neuro issues, same as list for increased risk for infection
Braden Scale
checks for risk of skin breakdown, the more points, the less likely for skin breakdown, 12 or less = high
risk
Pressure Ulcers
-capillary displacement -> lack of blood flow = lack of O2 -> ischemia -> necrosis
Factors for Pressure Ulcers
-intensity: intense pressure or light pressure over a long time
-duration
-tolerance: how strong is skin, health, malnourished?
Stage I Pressure Ulcer
-non-blanchable erythema
Stage II Pressure Ulcer
-partial thickness loss of dermis
-shallow open ulcer with red pink wound bed
-open or intact blister
, Stage III Pressure Ulcer
-full thickness skin loss
-subcutaneous fat may be visible
-tunneling or undermining
Stage IV Pressure Ulcer
-full thickness tissue loss
-visible muscle, bone, tendon
-undermining
Describing a Wound
-measure
-look at wound bed itself
-describe (yellow)
-tunneling/undermining (describe like a clock, cm)
-drainage (purulent, serous, serosanguinous (pink tinge), sanguinous (bleeding)), amount of drainage
(scant, small, moderate, excessive amount)
-odor
Skin Shear
-friction (a force that occurs in a direction to oppose movement), force exerted against the skin while the
skin remains stationary
Skin Tear
tear in skin from something
Prevention of Skin Breakdown
-nutrition, change brief consistently (acidity), barrier cream
Types of Wound Healing
