NURSING 220-EXAM 1 QUESTIONS WITH CORRECT ANSWERS

NURSING 220-EXAM 1 QUESTIONS WITH CORRECT ANSWERS A patient is placed in contact precautions due to an infection caused by methicillin-resistant Staphylococcus aureus. The nurse prepares to provide colostomy care. Which PPE are needed? A. Gown and gloves. B. Gloves and goggles C. Gloves, gown, and mask D. Gloves, gown, goggles and/or face shield - Answer-D nosocomial - Answer-originating in hospital iatrogenic - Answer-from a procedure HAI - Answer-healthcare associated infection medical asepsis - Answer-clean technique surgical asepses - Answer-sterile technique endogenous - Answer-when patients flora becomes altered and overgrowth results HAI - Answer--risks: Number of health care employees with direct contact with the patient, Types and numbers of invasive procedures, Therapy received, Length of hospitalization -Major sites for HAI infection: Surgical or traumatic wounds, Urinary and respiratory tracts, Bloodstream soap and water vs. alcohol rub - Answer-SOAP & WATER -Hands visibly dirty or contaminated -C. Diff -Wet hands ALCOHOL-BASED RUB -More effective and quicker -Less damaging to skin -Less time -More accessible factors that influence hygiene - Answer--Social Practices -Personal Preference -Body Image -Socioeconomic Status -Health Beliefs and Motivation -Cultural Variables (see Box 40-1) -Developmental Stages Physical Condition HAPU - Answer--hospital acquired pressure ulcer -Devices secured too tightly (ET tubes, trach plates, SCDs) -Poor positioning of devices -Skin unobservable -Lack of awareness of impact of edema -Prolonged pressure in same location -Alerted microclimate (increased moisture, heat) -Equipment/discards left in bed -Excessive layers under patient -Failure to check tubing location mobility - Answer--The ability to move freely from one point to another. -coordinated body mechanics -alighment -balance components of mobility - Answer--Bones -Skeletal muscles -Nervous system benefits of mobility - Answer--Promotes body systems functioning -Provides means of self protection -Allows for performing activities of daily living (ADLs) effects of immobility - Answer-Physiological: -Weakness, deconditioning (Disuse Syndrome) Psychological: -Sensory alterations -Coping/altered sleep Psychosocial: -Isolation/loneliness systemic hazards of immobility - Answer--Respiratory (pneumonia) -Cardiovascular (orthostatic hypotension) -Musculoskeletal Changes (loss of endurance and muscle mass) -Muscle effects (muscle atrophy) -Skeletal effects (impaired calcium absorption) -GI/GU (urinary stasis, renal calculi) -Integumentary (pressure ulcer, ischemia) -Metabolic (endocrine, calcium absorption, GI function) when to reposition - Answer--bedrest: every 2 hours -chair bound: limit to 1 hour and shift weight every 15 minutes antiembolitic devices - Answer--TEDS: (thrombosis embolism deterrent stockings) aid in maintaining external pressure on the muscles of the lower extremities and thus promote venous return. -SCD: Sequential Compression Devices -IPC: Intermittent Pneumatic Compression how to use crutches: - Answer--Top of crutches - between 1 to 2 inches below your armpits while standing up straight. -Handgrips - even with the top of hips pulse deficit: - Answer--difference between apical and radial pulse pulse pressure - Answer--difference between systolic and diastolic pressure PPE for airborne: - Answer--mask or N95 -negative pressure room -private room -examples: measles, varicella zoster, TB PPE for droplet: - Answer--mask or N95 -private or cohort room -examples: diphtheria, pertussis, mumps, pneumonic plague PPE for contact: - Answer--gloves -gown -private or cohort room -examples: VRE, MRSA Bullying in the workplace, withholding information, making snide remarks or put downs are examples of: - Answer-lateral violence Medications that decrease respirations include: - Answer--Anesthetics -Opioids normal capnography (EtCO2) range: - Answer-35-45 According to Maslow's hierarchy of needs, which basic needs must be met before physical and psychological safety and security can be addressed? - Answer--oxygenation, temperature, and nutrition A patient is diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. Which type of isolation precaution is most appropriate for this patient? - Answer--Droplet precautions PPE put on order: - Answer--Gown -Mask -Eyewear -Gloves PPE take off order: - Answer--Gloves -Eyewear -Gown -Mask emotional intellegence - Answer--assessment and communication technique that allows nurses to bettie understand and perceive the emotions of themselves and others when to use doppler: - Answer--when you cannot hear heart beats with stethoscope pulse sites: - Answer--temporal -carotid -apical -brachial -radial -ulnar -femoral -popliteal -posterios tibial -dorsalis pedis