NUR 103 REVIEW (ANSWERED) 86
QUESTIONS AND CORRECT
ANSWERS. 1005 CORRECT. 2024/2025.
Identify the Standard Precautions used in patient care:
1. Hand Hygiene
2. Use of PPT
3. Safe injection practices
4. Safe handling of potentially contaminated equipment.
5. Respiratory hygiene
6. Cough etiquette.
CDC Guidelines for hand washing:
1. Turn on water and wet hands
2. apply soap and scrub thoroughly for approximately 30 seconds
3. rinse soap off hands with fingers pointing downward
4. dry hands finger tips to wrist, completely.
5. turn off sink using paper towel.
What conditions place patients at risk for impaired skin integrity and why?
1. Immobilization: restricted to moving freely, body parts lose circulation, and pressure ulcers occur.
2. Reduced Sensation: w/ paralysis, circulatory insufficency on local nerve damage are unable to
sense skin injury.
3. Nutrition and Hydration: patients w/ limited caloric and protein intake develop thinner, less elastic
skin, which results in delayed wound healing.
4. Secretions or excretions on skin: medium for bacterial growth and healing, and can cause skin
breakdown.
Female Perineal care:
Place waterproof pad under patients buttocks, wash from pubic area towards the rectum, wash
middle and both sides of perineum, use separate cloth for each stroke. Clean front to back.
Male Perineal care:
Wash the tip of the penis at urethral meatus first, using circular motion, clean from meatus onward.
Discard washcloth and repeat w/ new cloth until penis is clean.
Define the concept of Inflammation:
an immunologic defense against tissue injury, infection, or allergy. it is a protective process initiated
to minimize or remove the agent triggering the inflammation
Identify Risk factors of INFLAMMATION:
- Presence of autoimmune disease or allergies
-exposure to pathogens w/ or w/out resultant infection
, -many autoimmune disease have genetic basis for predisposition
• Absence of effective hand hygiene
• Living in small spaces with large amounts of people
• Poor sanitation
• Absence of the use of standard precautions
• Smoking
• Pollution
• Exposure to repeated trauma
At risk populations for inflammation:
• Very young: not a mature immune system, breast feeding rate is low, children do not have their
mothers immunity
• Very old: mobility and immune system
• Uninsured: do not have early access to intervention, may not be vaccinated
Clinical Manifestations of Inflammation:
-heat
-redness
-swelling
-pain
-fatigue
-increase in plasma proteins
-fever
-exudate
Interventions to manage inflammation:
You can intervene by mediating the inflammatory process to promote repair and healing and avoid
excessive inflammatory response that could lead to further tissue damage
Interrelated concepts pertaining to inflammation:
1. Immunity and infections: many parts of immunity and infection are associated with inflammation
2. Tissue Integrity: at risk in an inflammatory response, as is impaired mobility and pain.
3. Thermoregulation: influenced by inflammation depending on severity.
Exudate:
A mass of cells and fluid that has seeped out of blood vessels or an organ.
Granuloma:
A mass of granulation tissue typically produced in response to infection, inflammation, or the
presence of a foreign subject.
Hyperemia:
an excess of blood in vessels supplying an organ or another part of the body.
Chemotaxis:
movement of cells or oganisms in response to chemicals.
QUESTIONS AND CORRECT
ANSWERS. 1005 CORRECT. 2024/2025.
Identify the Standard Precautions used in patient care:
1. Hand Hygiene
2. Use of PPT
3. Safe injection practices
4. Safe handling of potentially contaminated equipment.
5. Respiratory hygiene
6. Cough etiquette.
CDC Guidelines for hand washing:
1. Turn on water and wet hands
2. apply soap and scrub thoroughly for approximately 30 seconds
3. rinse soap off hands with fingers pointing downward
4. dry hands finger tips to wrist, completely.
5. turn off sink using paper towel.
What conditions place patients at risk for impaired skin integrity and why?
1. Immobilization: restricted to moving freely, body parts lose circulation, and pressure ulcers occur.
2. Reduced Sensation: w/ paralysis, circulatory insufficency on local nerve damage are unable to
sense skin injury.
3. Nutrition and Hydration: patients w/ limited caloric and protein intake develop thinner, less elastic
skin, which results in delayed wound healing.
4. Secretions or excretions on skin: medium for bacterial growth and healing, and can cause skin
breakdown.
Female Perineal care:
Place waterproof pad under patients buttocks, wash from pubic area towards the rectum, wash
middle and both sides of perineum, use separate cloth for each stroke. Clean front to back.
Male Perineal care:
Wash the tip of the penis at urethral meatus first, using circular motion, clean from meatus onward.
Discard washcloth and repeat w/ new cloth until penis is clean.
Define the concept of Inflammation:
an immunologic defense against tissue injury, infection, or allergy. it is a protective process initiated
to minimize or remove the agent triggering the inflammation
Identify Risk factors of INFLAMMATION:
- Presence of autoimmune disease or allergies
-exposure to pathogens w/ or w/out resultant infection
, -many autoimmune disease have genetic basis for predisposition
• Absence of effective hand hygiene
• Living in small spaces with large amounts of people
• Poor sanitation
• Absence of the use of standard precautions
• Smoking
• Pollution
• Exposure to repeated trauma
At risk populations for inflammation:
• Very young: not a mature immune system, breast feeding rate is low, children do not have their
mothers immunity
• Very old: mobility and immune system
• Uninsured: do not have early access to intervention, may not be vaccinated
Clinical Manifestations of Inflammation:
-heat
-redness
-swelling
-pain
-fatigue
-increase in plasma proteins
-fever
-exudate
Interventions to manage inflammation:
You can intervene by mediating the inflammatory process to promote repair and healing and avoid
excessive inflammatory response that could lead to further tissue damage
Interrelated concepts pertaining to inflammation:
1. Immunity and infections: many parts of immunity and infection are associated with inflammation
2. Tissue Integrity: at risk in an inflammatory response, as is impaired mobility and pain.
3. Thermoregulation: influenced by inflammation depending on severity.
Exudate:
A mass of cells and fluid that has seeped out of blood vessels or an organ.
Granuloma:
A mass of granulation tissue typically produced in response to infection, inflammation, or the
presence of a foreign subject.
Hyperemia:
an excess of blood in vessels supplying an organ or another part of the body.
Chemotaxis:
movement of cells or oganisms in response to chemicals.
