EXAM 1 NURSING PROCESS, SAFETY, INFECTION CONTROL, AND SKIN INTEGRITY-103 QUESTIONS AND ANSWERS

What causes illness? (Most basic concept) Bacteria What other organisms cause illness? Fungus, parasites, bacteria/virus (most likely seen in hospitals), and protozoa. Brainpower Read More 0:10 / 0:15 How does the chain of infection go? (6 steps) Infectious agent to reservoir to portal of exit to mode of transmission to portal of entry to host. Put the stages of infection in the correct order. A. Illness stage B. Convalescence C. Incubation period D. Prodromal stage C D A B What is the interval when the pt manifests SXS specific to type of infection (Ex: Strep throat is manifested by sore throat, pain, and swelling)? Illness stage What is the interval when acute symptoms of infection disappear? Convalescence stage What is the interval between entrance of pathogen into body and appearance of first symptoms (Ex: Chickenpox, 14-16 days after exposure, common cold, 1-2 days, influenza, 1-4 days)? Incubation stage What is the interval from onset of nonspecific SXS to more specific symptoms (Ex: Herpes simplex begins with itching and tingling at the site before the lesion appears)? Prodromal stage The pt and the nurse are discussing Rickettsia rickettsii--Rocky Mountain spotted fever. Which pt statement to the nurse indicates understanding regarding the mode of transmission for this disease? The pt states, "When camping, A. "I will use sunscreen" B. "I will drink bottled water C. "I will wear insect repellent" D. "I will wash my hands with hand gel" C. (Rickettsia rickettsii is transmitted by ticks) The nurse is providing an educational session for a group of preschool workers. The nurse reminds the group about the MOST important thing to do to prevent the spread of infection. Which information did the nurse share with the preschool workers? A. Encourage preschool children to eat a nutritious diet B. Suggest that parents provide a multivitamin to the children C. Clean the toys every afternoon before putting them away D. Wash their hands between each interaction with children D. What does SBAR stand for? Situation, Background, Assessment, and Recommendation Two days postoperatively, the nurse's assessment indicates that the incision is red and has a small amount of purulent drainage. The patient reports tenderness at the incision site. The patient's temp was 100.5 F, and the WBC is 10,500/mm3. Which action should the nurse take FIRST? A. Plan to change the surgical dressing during the shift B. Utilize SBAR to notify the primary HCP C. Reevaluate the temp and WBC count in 4 hours D. Check to see what solution was used for skin preparation in surgery B. Hgb over.... Hct WBC over... Platlets What do you look for when assessing WBCs? 5,000-10,000 is considered normal. -Look for trends in WBC counts -Look for really high or really low values What occurs when a pt will experience localized SXS such as pain, tenderness, warmth, and redness at wound site? Localized infection What is an infection that effects the entire body instead of just a single organ and can become fatal if undetected and untreated (Look for change in VS and health status)? Systemic infection What does REEDA stand for? Redness, edema, ecchymosis, discharge, and approximation of the wound edges. The nurse is caring for a group of medical surgical patients. Which patient is most at risk for developing an infection? A. A pt who is in observation for chest pain B. A pt who has been admitted with dehydration C. A pt who is recovering from right total hip surgery D. A pt who has been admitted for stabilization of heart problems C. The nurse is caring for a patient who is susceptible to infection. Which instruction will the nurse include in an educational session to decrease the risk of infection? A. Fall prevention B. How to take temp C. Choosing nutritious foods D. The effects of smoking D. (Smoking can increase the risk of infection) A-Prevents injury not infection B-Detects SXS not risk of infection The pt has contracted a UTI while in the hospital. Which action will MOST likely increase the risk of a pt contracting a UTI? A. Reusing the its graduated receptacle to empty the drainage bag B. Allowing the drainage bag port to touch the graduated receptacle C. Emptying the urinary drainage bag at least once a shift D. Irrigating the catheter infrequently B. The nurse is caring for a pt who is at risk for infection. Which action by the nurse indicates correct understanding about standard precautions? A. Teaches the pt about good nutrition B. Dons gloves when wearing artificial nails C. Disposes an uncapped needle in the designated container D. Wears eyewear when emptying the urinary drainage bag C. What is the term for coming from microorganisms found outside the individual such as Salmonella? Exogenous What is the term for when part of the flora becomes altered and an overgrowth results? Endogenous What is a type of HAI caused by an invasive diagnostic or therapeutic procedure? Iatrogenic What develops when broad-spectrum antibiotics eliminate a wide range of normal flora organisms, not just those causing infection (An infection on top of the previous infection that is already occurring)? Suprainfection What is MDRO? Multi-Drug Resistant Organism What is the term for when there are very few/little organisms are present? Ex: Hand hygiene, barrier techniques, and routine environmental cleaning. Medical asepsis (Clean technique) What is the term for when they are no organisms present and this prevents contamination of an open wound, serves to isolate an operative area from the unsterile environment, and maintains a sterile field for surgery? Surgical asepsis (Sterile technique) What does CAUTI mean? Catheter Associated UTI What does SSI mean? Surgical Site Infection What does CLABSI mean? Central Line Associated Blood Stream Infection The nurse is caring for a pt who has cultured positive for Clostridium difficile. Which action will the nurse take NEXT? A. Instruct assistive personnel to use soap and water rather than sanitizer B. Wear a N95 respirator when entering the pt room C. Place the pt on droplet precautions D. Teach the pt cough etiquette A. The nurse is caring for a pt that has a blood born pathogen. The nurse splashes blood above the glove to intact skin while discontinuing an IV infusion. Which step(s) will the nurse take NEXT? A. Obtain an alcohol swab, remove the blood with an alcohol swab, and continue care B. Immediately wash the site with soap and running water, and seek guidance from the manager C. Do nothing; accidentally getting splashed with blood happens frequently and is a part of the job D. Delay washing of the site until the nurse is finished providing care to the pt B. What precautions focus on diseases that are transmitted by large droplets expelled into the air and by being within 3 ft to a pt? Droplet precautions What precautions are used for direct and indirect contact with its and their environment? Contact precautions What precautions focus on diseases that are transmitted by smaller droplets, which remain in the air for longer periods of time? Airborne precautions What precautions focus on a very limited pt population that protects the pt against outside infections and trying to protect their immune responses? Protective precautions or reverse isolation What does it mean to clean? To remove organic material or inorganic material from objects and surfaces. What does it mean to disinfect? It eliminates many or all microorganisms, with the exception of material spores, from inanimate objects. What does it mean to sterilize? Eliminates or destroys all forms of microbial life, including spores. What is a pressure ulcer that is non-blanchable erythema of intact skin usually over bony prominences. When palpated the erythema does not go away (Look @ temp-cold/warm, turgor, pain/loss of sensation, and texture of skin)? Stage I What is a pressure ulcer that has partial-thickness skin loss with exposed dermis (non-intact skin) presenting as a shallow open ulcer with a red pink wound bed? Stage II What is a pressure ulcer that has full-thickness tissue loss and subcutaneous fat may be visible but bone, tendon, and muscle are not expose? Stage III What is a pressure ulcer that has full-thickness tissue loss with exposed bone, tendon, or muscle that could increase the pts risk of developing osteomyelitis? Stage IV What is a pressure ulcer that is obscured full-thickness tissue loss and skin loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed? Unstageable What is a pressure ulcer that is persistent non-blanchable deep red, maroon, or purple discoloration of skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear? Suspected deep tissue injury (sDTI) Name some risk factors for skin integrity. Impaired sensory perception, impaired mobility, alteration in LOC, shear, friction, and moisture (occurs with pts in fowler's or semi-fowler's position). What is the sliding movement of skin and subcutaneous tissue while the underlying muscle and bone are stationary? Shear What is the force of 2 surfaces moving across one another such as the mechanical force exerted when skin is dragged across a coarse surface such as bed linens? Friction What is the presence and duration of moisture on the skin increases the risk of ulcer formation (tends to be from incontinence, but can also occur from sweat, blood, wound drainage, etc.)? Moisture What is a primary intention? A clean surgical incision is an example of a wound with little tissue loss. This heals from the outside, in. What is secondary intention? A wound involving loss of tissue such as burn, pressure ulcer, or severe laceration. This heals from the inside, out. What are the stages of full-thickness wound repair? Hemostasis, inflammatory phase, proliferative phase, and maturation. What is the hemostasis phase? Injured blood vessels constrict, and platelets gathers to stop bleeding. What is the inflammatory phase? Damaged tissue and mast cells secrete histamine, resulting in vasodilation of surrounding capillaries and movement/migration of serum and WBCs into the damaged tissues. What is the proliferative phase? This is where the new cells begin to maintain tissue integrity. What is the maturation phase? It is the final stage of healing, sometimes takes place for more than a year, depending on the depth and extent of the wound. What is sanguineous drainage? Bloody drainage What is serosanguineous drainage? Pale pink, thinner, contains plasma and red blood cells (watery/ not thick like blood). What is serous drainage? Pale yellow, watery drainage (presence of blood may indicate a blood blister). What is purulent drainage? Contains microorganisms and is thick, pale yellow, green, and tan (NOT normal; look into infection possibility). Name some complications with wound healing. Hemorrhage, hematoma, and infection. What is a hemorrhage? Can be external or internal bleeding. What is a hematoma? Where blood pools under the skin. It can be raised and painful and possibly fluid filled. What is are signs of an infection in a wound? Purulent drainage, prolonged edema, irregular erythema, delayed healing, pain, fever, and elevated WBC. What is dehiscence? When the edges are not together on a wound. What is evisceration? When visceral organs come out of a wound. What are factors that influence wound healing? Nutrition, tissue perfusion, infection, age, and psychosocial. Can a nursing assistant empty drainage systems? Yes, BUT the nurse needs to evaluate the drainage. What are the 5 steps of the nursing process? Assess, diagnose, plan, implement, and evaluate The nursing dx Impaired Parenting r/t mother's developmental delay is an example of; A. Risk nursing dx B. Problem-focused nursing dx C. Health promotion nursing dx D. Wellness nursing dx B.