NURS 206 EXAM 1 (Questions and Answers A+ Graded 100% Verified)

NURS 206 EXAM 1 (Questions and Answers A+ Graded 100% Verified) MODULE 1 what are the 2 defenses against infection ANS: normal flora immune response what is involved in immune response? ANS: innate immunity adapt immunity inflammatory response type of immunity that is long term/ specific/ acquired ANS: adaptive immunity -Adaptive immunity is antigen specific and involves active, long-term Immulogic memory what are the types of adaptive immunity? ANS: humoral cellular immunologic memory anti-body mediated Defense system that involves white blood cells (B lymphocytes) that produce antibodies in response to antigens or pathogens circulating in the lymph and blood ANS: humoral cell mediated Involves defense by white blood cells against microorganisms that the body does not recognize as its own -B cells, T lymphocytes, and macrophages ANS: cellular what is the first life of defense against infection? ANS: normal flora what is the second line of defense against infection? ANS: inflammatory response what type of immunity is short term/ non specific ANS: innate immunity is a local response to cellular injury or infection that includes capillary dilation and leukocyte infiltration -produces redness, heat, pain, and swelling ANS: inflammatory response what other body systems help with defense against infection? ANS: integumentary respiratory gastrointestinal What is the path for the chain of infection? ANS: infectious agent source/ reservoir portal of exit mode of transmission portal of entry susceptible host what are some different types of infectious agents? ANS: bacteria virus parasite fungus what is infection? ANS: the invasion of a host/ patient by a microorganism what needs to happen in order for a microorganism to produce disease? ANS: the organism needs to multiply and alter normal tissue function risk of infectious agent causing disease depends upon: ANS: -the number or organisms -virulence of organisms -ability of organism to enter and survive in the host -susceptibility of the host/ patient susceptibility of the host depends upon: ANS: -age -nutritional status -presence of chronic disease -trauma -smoking where the organism survives and multiples and is the holding area ANS: source/ reservoir examples of sources/ reservoirs ANS: -animal/ insect -intimate object (hospital equipment or food/water? -human being (can be symptomatic or asymptomatic- carry disease but no active sign of disease) what characteristics promote growth of an organism at the source? ANS: -food (undigested) -O2 -water (moist) -temperature (cold prevents growth, so warm) -pH (5.0-7.0) -light (dark) after an organism grows and multiplies it needs a way to exit the reservoir and enter the host, this is called... ANS: the portal of exit what are the different portals of exit? ANS: respiratory tract GI tract GU tract blood skin/mucous surface reproductive tratt transplacental how the organism transports from source to susceptible host ANS: mode of transmission types of transmission ANS: direct -direct contact with organism -sexual contact, airborne, enteric, droplet indirect -organism is transported another way -vector. insect contaminated equipment -contaminated food. (food poisoning or water -can be more than one Mode where an organism enters through the same route as the portal of exit ANS: PORTAL OF ENTRY GI tract -foodborne illness GU tract -wiping back to front respiratory tract -droplets from a sneeze mucous membrane blood -needles/ IV non intact skin -open wound reproductive tract -multiple sexual partners transplancental what is it called when a patient is not able to resist the bombardment of large numbers of organisms ANS: susceptible host things that make people considered susceptible hosts... ANS: infants and elderly immonosuppressed trauma surgery chronic disease poor nutrition smoking multiple drug resistant organism different medication can weaken immune systems what it the ecology/ cause of multiple drug resistant organisms ANS: inappropriate use of antibiotics causes bacteria to be resistant to antibiotics that once worked formerly referred to as nosocomial infections, are infections acquired while the patient is receiving treatment in a health care facility -Associated with the use of medical devices, complication, contagious transmission, and the overuse of antibiotics ANS: health-care associated infections -microorganism developing resistance to medication -A microorganism is considered resistant if replication cannot be stopped by 2 or more antibiotics simultaneously or sequentially -Contributing factors: overprescribing of antibiotics for nonbacterial infections, incomplete course of antibiotics ANS: resistant organisms Can put patients and health care providers at risk Ex. Hep B virus, Hep C virus, HIV Exposure occurs through contact with contaminated blood or body fluid ANS: blood borne pathogens signs and symptoms of an infection depend on... ANS: the type and location of the infection -can be localized (one body part/ system) or systemic (bloodstream) -different diversity considerations as well what are the steps of the nursing process? ANS: ASSESS DIAGNOS PLANNING INTERVENTION EVALUATION assessment when in comes to infection control... what is performed/ assessed? ANS: perform an interview -comprehensive health history -patients clinical experience -exceptions -clusters of defining characteristics what kinds of things are assessed in a comprehensive health history for infection control? ANS: -history of illnesses/ treatment? -open areas on skin -recent invasive diagnostic testing -pain with urination -medication they are taking -history of fever -travel *assess for clues/factors that increase susceptibility in localized infection... what should a nurse do? ANS: -wear exam gloves -assess the affected area for: redness, edema (swelling), exudate(drainage), pain/tenderness, and restriction in movement of body part in a systemic infection what signs/ symptoms could the patient have? ANS: fever fatigue nausea/ vomiting tenderness of lymph nodes drainage at sit of infection abnormal lab values (elevation of white blood cells or positive blood/ body fluid culture) EXCEPTIONS: in older adults the usual signs and symptoms may be absent in infection. instead they could exhibit... ANS: confusion fatigue agitation incontinence (unable to control urination) what vital signs could change due to infection ANS: temp, pulse, and respiration may increase -BP decreases with septicemia what are good laboratory and diagnostic tests to take for infection ANS: CBC complete blood count WBC white blood count culture and sensitivity of body fluids ESR erythrocyte sedimentation rate DIAGNOSES related to infection ANS: -Risk for infection -Knowledge deficit of causes of infection -Impaired skin integrity -Imbalanced nutrition when planning... make sure goals ANS: are attainable by patient after discharge home -based off of diagnosis -are prioritized -are collaborated with others examples of planning ANS: -Patients incision will remain infection free during hospitalization -Patient will maintain good personal hygiene by the end of day 3 after admission -Patients open area on the coccyx will decrease in size by the end of day 4 after admission -Patient will consume 50% of all meals and supplements implementations for preventing the development and spread of infection ANS: -wash hands -disinfect equipment -use disposable equipment in patients suspected to infection -use PPE -adopt asepsis techniques what are the 2 types of asepsis? ANS: medical (clean technique) surgical (sterile technique) what falls under the category of medical asepsis? ANS: STANDARD precautions and TRANSMISSION based precaustions Standard precautions are- principles and procedures that prevent the spread of infection... what do they include? ANS: HAND HYGIENE PPE personal protective equipment hand hygiene is the most important medical asepsis technique.. when should you perform it? ANS: -When hands are visibly dirty, before and after eating, after using the toilet, after exposure to spore forming organisms -Before sterile gloving -before assessing a patient ***Alcohol based sanitizer is acceptable in some cases like when Hands are not visible soiled- patient has intact skin, after contact with environmental surfaces in patients room, before putting gloves on, after removing gloves PPE includes... ANS: gloves mask goggles face shields gowns caps shoe coverings precautions and isolation for patients with a known organism ANS: Transmission based precautions Isolation Precautions and Transmission Based Precautions can be used interchangeably. The best protection is offered by an _________________ that has an ante-room (vestibule) that precedes entry into the patient's private room. Has sink for handwashing and PPE supplies. The 2nd best option is _________outside of patient's room on door. Notice that the type of isolation sign is displayed on door. Gowns, gloves in various sizes, goggles, and masks are available in the pockets. Wipes for cleansing equipment. Hamper and Isolation trash receptacle should be next to door. ANS: isolation room supplies what are the different types of transmission based precautions? ANS: contact precautions airborne precautions droplet precautions protective precautions Transmitted by smaller droplets that remain in the air longer Patient is placed in negative air flow room with HEPA filtration that vents to outdoors N95, goggles, gloves ANS: airborne precautions examples of airborne microorganism / disease ANS: tuberculosis varicella (chicken pox) measles Indicated with direct (patient's body fluid) or indirect contact (healthcare workers hands or contaminated equipment) ANS: contact precautions examples of contact microorganism / disease ANS: MRSA C. difficile Transmitted by large droplets ANS: droplet precautions examples of droplet microorganims/ diseases ANS: FLU pertussis stop pharyngitis -For severely immunocompromised patients -POSITIVE airflow with HEPA filtration (air leaves the room without circulating back in) -Provide thermometer, BP cuff, and stethoscope for this patient only -Gloves, gown, masks to protect patient from exposure -Patients having WBC < 500 -Used in post op transplant patients ANS: protective precautions what are the goals of medical asepsis? ANS: -To reduce the number of organisms -To prevent the transmission of organisms each patient should have own set or personal care items like... ANS: bedpan urinal basin what does surgical asepsis include? ANS: preparation of sterile field and sterile gloving Contamination is defined as... ANS: an object that contains OR is suspected of containing pathogens (organisms) what are some examples of contaminated equipment ANS: A used bedpan A soiled dressing A patients over-bed table Side rails of a bed A patients call light what are the goals of surgical asepsis? ANS: -ELIMINATION of sources of organism in an area -PREVENTION of microbial contamination of an open wound of the skin -ISOLATION of the operative area from the rest of the unsterile environment -MAINTENANCE of the sterile field in surgery and at the patient's bedside during certain procedures where is surgical asepsis used? ANS: -Operating rooms, -labor and delivery rooms, -diagnostic rooms, -clients bedside (IV, catheter, suctioning, sterile dressings) interventions to prepare the patient when using surgical asepsis ANS: -Educate patient not to move and potentially contaminate sterile field -Tell patient approximately how long the sterile procedure will take -Ask patient to use toilet/ bedpan if needed before the start of procedure -Assist patient to a comfortable position a sterile object remains sterile only when... ANS: touched by another sterile object what is the only thing that can touch the sterile field ANS: sterile gloves and sterile supplies a sterile package is considered contaminated if... ANS: torn wet open punctured true or false... A sterile field or object out of your range of vision OR held below you waist is contaminated ANS: TRUE A sterile field or object will become contaminated by prolonged exposure to... ANS: air- avoid drafts, coughing, sneezing When a sterile field or object comes in contact with a wet surface it becomes contaminated by... ANS: capillary action the edges of a sterile field or open package are considered... ANS: contmainated 1 inch border sterile field cannot hang over table some hints when performing sterile procedures ANS: -assemble all of the equipment that will be needed BEFORE beginning, you cannot leave the room once they are opened -have an EXTRA supply of each sterile supply in case of accidental contamination -give an explanation before sterile procedure so patient will cooperate -when sterility is in doubt... THROW IT OUT is the removal of pathogenic microorganisms; usually kills all pathogenic microorganisms except spores ANS: disinfection is a process used to destroy all microorganisms, including their spores ANS: sterilization Usually done by central supply department in hospital Done by steam under pressure or by chemicals/gas What a nurse needs to know Procedure for handling items needing sterilization Procedure for returning equipment to central supply Process by which an individual becomes develops immunity against a specific agent; important in preventing the spread of communicable diseases ANS: immunization -By receiving all of the recommended doses of vaccines against communicable diseases, the patient develops immunity. -It is important that the entire series of vaccines are received at the recommended frequency for the patient to develop immunity. For this reason, healthcare workers receive the Hepatitis B immunization due to the healthcare workers higher risk of exposure to patients' blood and body fluids. Also the reason why grandparents receive the whooping cough vaccine, so not to infect newborn grandchildren. an infectious agent that causes disease ANS: Microorganisms/ pathogens are single cell organisms ANS: Bacteria single cell organisms that can cause infection (molds and yeasts) ANS: fungi examples of normal flora ANS: Bacteria, fungi, protozoa carry the pathogens from one host to another () ANS: vectors is the equipment that health care personnel use to protect against the spread of infectious ANS: Personal protective equipment (PPE) is a substance that provokes an adaptive immune response ANS: antigen are immunoglobulin molecules that recognize foreign invaders ANS: antibodies PPE for contact precautions ANS: gloves and gown PPE for airborne precautions ANS: N95! gloves, face shield, goggles, gown PPE for droplet precautions ANS: gloves, gown, mask face shield PPE for immunocompromised patients ANS: gown mask gloves goggles how should you wash and dry your hands? ANS: wash from wrist to fingertips dry from fingertips to wrist what is the correct order for DONNING PPE? ANS: *wash hands gown mask goggles gloves what is the correct order for DOFFING PPE? ANS: gloves goggles gown mask *wash hands MODULE 2 ANS: MODULE 2 first step in the nursing process that established the baseline in which each phase of the nursing process builds ANS: ASSESSMENT -individual patient focused plan of care can be established based on information that was gathered what are the 3 components of a health assessment? ANS: Health history, physical examination, documentation what kind of data comes from a health history interview/ assessment? ANS: subjective/ symptoms what kind of data comes from a physical examination? ANS: objective/ signs what in involved in a health history? ANS: biographical information Current state of health Medications they take Previous illnesses/ surgeries Family history Review of symptoms what is involved in a physical examination? ANS: Inspection Palpation Percussion Auscultation Patient's height, weight, blood pressure, temperature, pulse rate, and respiration rate (VITALS) documentation should be.. ANS: complete, accurate, without bias/ opinion, at point of care, and descriptive what is the importance of documentation? ANS: -improves plan of care and prevents the patient from having to repeat themselves to other healthcare workers -The health record serves as the legal permanent record of the patients health status at the time of health care encounter- which means it serves as the baseline for evaluation of subsequent changes and decisions related to care Formats of Documentation ANS: EHR- electronic health record paper comes directly from the patient ANS: primary data information shared by family members, friends, or other members of the healthcare team, charts, medical records, or results of lab tests ANS: secondary data spoken information symptoms that cannot be authenticated ANS: subjective data can be measured or observes signs ANS: objective data what are the different types of physical examinations? ANS: comprehensive assessment focused assessment emergency assessment which physical assessment is the most common type conducted by nurses? ANS: FOCUSED assessment Complete assessment includes a thorough interview, health history, review of systems, and extensive physical head to toe assessment, including evaluation of cranial nerves and sensory organs, such as sight and hearing testing -Often include a variety of laboratory and diagnostic tests that are ordered by the primary care provider ANS: comprehensive assessment Or clinical assessment is a brief individualized physical examination conducted at the beginning of an acute care- setting work shift to establish current patient status or during ongoing patient encounters in response to a specific patient concern -May be conducted when sign indicate a change in a patient's condition or the development of a new complication -Vital signs are taken- which includes pain level and pulse oximetry -Nurse examines the head, eyes, ear, nose, throat, neck, thorax, abdomen, and extremities ***Basic head-to-toe assessment ANS: focused assessment is a physical examination done when time is a factor, treatment must begin immediately, or priorities for care need to be established in a few seconds or minutes Attention is paid to the patients airway, breathing, and circulation Triage- form of emergency assessment ANS: emergency assessment when developing a nursing diagnosis and care plan you should consider different home care considerations such as... ANS: -government and community resources Transportation School and tutoring service Library resources Fire and safety resources Economic resources Recreation -social service agents Meal preparation and deliveries Utility assistance Day care facilities for all age groups Cleaning and home maintenance assistance -public and home health services Immunizations Environmental surveillance Medical equipment Medication delivery What should you do in order to prepare for an examination? ANS: infection control- check for latex allergy make sure there is a good environment gather all necessary equipment prep the patient- put them in the correct position PREVENTING latex allergy ANS: -Use nonlatex gloves for any activities that are not likely to involve contact with infectious materials -If latex gloves are to be used, use a powder free, low-allergen glove if possible -Do not use oil based hand lotions when wearing latex gloves Immediately after removing latex gloves, -wash the hands with mild soap and dry them thoroughly *routinely ask patients about latex allergy what should you consider in terms of a good and comfortable environment for patient examination? ANS: -make sure its clean -privacy -no interruptions -good lighting -warm temp -furnished -bed near waist What is all of the necessary equipment (8) you should gather for examination? -everything should be readily available, accessible, and functional ANS: thermometer stethoscope blood pressure equipment pulse oximeter scales for height and weight visual acuity charts ophthalmoscope what are the different types of thermometers and what are they used for? ANS: -disposable thermometer -electronic thermometer-axillary, oral, rectal (blood flowing near tissue surface) -tympanic membrane thermometer- ear -temporal artery thermometer- forehead (accurate for children 1-4 and adults in critical care) what is the most accurate way to obtain temperature ANS: RECTAL Used to auscultate sounds within the body that are not audible with the naked ear Several types but the ________ ______ is used routinely for a physical examination Transmits sound waves ANS: STETHOSCOPE acoustic stethoscope what are the 4 components of a stethoscope? ANS: earpeices binaural tubing head the diaphragm of a stethoscope is used for ___ pitch sounds ANS: high the bell of a stethoscope is used for ___ pitch sounds ANS: low Gauge, blood pressure cuff, and bulb with valve Use with a stethoscope to auscultate the blood pressure Accuracy of auscultation is affected by the nurses level of hearing ANS: Sphygmomanometer Operates by sensing circulating blood flow vibration through a blood pressure cuff sensor and converting these impulses into electric impulses- these impulses are converted to a digital readout Readout consist of- blood pressure, mean arterial pulse, and pulse rate Can be programmed to repeat measurements on a scheduled basis and alarm for certain results Not AS reliable as a manual blood pressure reading Variety of cuff sizes- use correct size for accuracy ANS: Electronic automated blood pressure device Used to measure the oxygen saturation In arterial blood ANS: Pulse oximeter -Consists of light- emitting diode (LED) probe connected by a cable to a monitor- the LED light emits light waves that reflect off oxygenated and deoxygenated hemoglobin molecules circulating in the blood- this reflection is used to estimate the oxygen saturation percentage in arterial blood and a pulse rate for older children and adults Scale should be calibrated to 0 before taking weight Pull up height attachment and then lower to top of head ANS: Standing platform scale what are the other types of scales? ANS: electronic infant platform what are the different types of visual acuity charts ANS: snellen/ e chart Rosenbaum chart 2 charts used for distance vision ANS: snellen and E chart Hung on the wall at a distance of 20 ft 11 lines of letter of decreasing size Top number of recording- indicates the distance between the patient and the chart Bottom number of recording- indicates the distance at which a normal person vision should be able to read that line of chart Color/ perception- red and green line ANS: snellen chart Same scoring as Snellen chart Describe as a table with legs and the patient must point to which direction the "legs" are pointing ANS: E chart Used to evaluate near vision and consists of a series of numbers, E's, X's, and O,s in different sizes 14 inches away from face ANS: Rosenbaum chart An instrument that consists of a series of lenses, mirrors, and light apertures permitting inspection of the internal structures of the eye Head and handle Can select lens focus/ strength- diopter Different light variations ANS: Ophthalmoscope what is done before EVERY assessment and are the most important things to remember ANS: -Wash hands, -identify the patient, -introduce yourself to the patient, -provide privacy, -explain purpose of procedure before and during assessment what is involved in psychological preparation of a patient? ANS: -Assess the pts emotional and physical abilities before initiating your physical examination. A comfortable patient will most likely be cooperative and easy to work with -Allow for support person to be present if requested -Ensure patients safety -Be sensitive to patients emotional and cultural needs what is the most common position for a patient? ANS: sitting and supine what does the patients position depend on? ANS: they type of examination they are getting- could be different if they have limitations what is the SITTING/FOWLER position and what is it used for ANS: used forauscultation and most vital signs -fowler is sitting position but fully in your bed without your feet dangling, legs stretched out but head of bed is elevated -expands lungs and easy to view symmetry SUPINE position and what its used for ANS: used for inspection- most normally relied position DORSAL RECUMBENT position and what its used for ANS: used in abdominal assessment -promotes relaxation of abdominal muscles LITHOTOMY position and what its used for ANS: used in assessing female genitalia -maximum exposure SIMS position and what its used for ANS: used in inspection -exposure to rectal area PRONE position and what its used for ANS: used in musculoskeletal assessment -extension of hip joint LATERAL RECUMBENT position and what its used for ANS: used mostly for listening to the heart -detects murmurs (left or right side) KNEE CHEST position and what its used for ANS: used for exposure of rectum key points to remember when positioning a patient ANS: -Explain procedure before starting, make patient comfortable -Provide privacy during examination (door shut and drape them) -Patient is most likely anxious prior to examination- reduce their anxiety -Ask the patient how they are doing what are the different developmental and diversity considerations? (5) ANS: life span culture/ethnicity/religion gender morphology disability life span considerations ANS: -May influence behavior and willingness to share personal information -A guardian or parent should be present when assessing an infant, child, adolescent, or special needs person culture, ethnicity, religion considerations ANS: -Affect willingness of patients to speak openly about health concerns -Nurses should explain