Fund Nur 50 - week 1.1

Question 1

ISBAR

Answer 1

I—Introduction

S—Situation

B—Background

A—Assessment

R—Recommendation

Q—Question and answer

Question 2

assessment

Answer 2

identify needs during hygiene, check skin, edema

Question 3

signs for skin (CTTJB

Answer 3

redness - esp over bony prominences, rash, temp and color, skin trigger, jaundice, cyanosis, ruddy of lower extremities, bruising.

Question 4

observe patients’ capabilities for hygiene - who is at risk…(PVD for hygiene)

Answer 4

older, bedridden, dementia, immune compromised, diabetes, PVD, dexterity, immobile, arthritis

Question 5

bathing - don’t make…

Answer 5

assumptions, ask questions

Question 6

if you delegate to a CNA, you need to make

Answer 6

parameters. Nurses can delegate. You are responsible for the oversight. ex - if a patient has a red area, CNA needs to notify you so you can perform an assessment.

Question 7

if patient has PVD or diabetes, only who can perform foot care?

Answer 7

nurse - can only perform assessment of foot care. No foot soaks for diabetics.

Question 8

partial bed baths

Answer 8

for patients who are very ill. bathing only body parts that cause discomfort or odor. under arms, under breasts, face, hands

Question 9

for independent showers, what criteria? (4 things)

Answer 9

1) can patient follow directions, 2) is the patient ambulatory, 3) has a steady gait w/out any dizziness 4) do you have an order for the patient to get up ad lib.

Question 10

during shower, wear..

Answer 10

PPE

Question 11

no baby powder

Answer 11

ever, in perineal care. Talc is gone now bc of potential cancer. Corn starch baby powder is contraindicated bc of pulmonary issues, inhilation, etc.

Question 12

shaving precautions or contraindications

Answer 12

anti-coagulents, bleeding disorder, if so, must use patient’s designated electric shaver. If patient has beard, you need verbal consent to shave it off, and document it as well.

Question 13

how often is oral care for unconscious patient?

Answer 13

every 2 hours. That includes oral care brushing and suctioning, and place them on their side when performing that care. Bacteria in teeth causes pneumonia

Question 14

reservoir

Answer 14

bacteria can survive, ex. fomite, health care workers’ hands

Question 15

portal of exit and entry

Answer 15

mouth, wound, gi tract, mucous, respiratory

Question 16

modes of transmission

Answer 16

droplet and airborne. droplet (large molecules) = coughing and sneezing. airborne = droplets suspended in air or dust

Question 17

modes of transmissions - vectors - types of illnesses

Answer 17

malaria, Zika, Lyme, Plague. and you need a susceptible host.

Question 18

try to have patient…

Answer 18

carry out as many activities on their own as possible, but provide assistance if needed.

Question 19

purpose of bathing (SCIA)

Answer 19

keep skin intact, promote comfort, prevent infection, assess patient.

Question 20

considerations when performing hygiene (needs)

Answer 20

patient’s preferences, values, and needs. More affluent patient, products might be important. Transient patient - maybe where they’re going to be discharged over the type of product used.

Question 21

culturally appropriate bathing

Answer 21

some cultures might not bathe for a period of time.

Question 22

geriatric patients

Answer 22

skin is very delicate, even tape can tear it. if there is a deficit, be careful. chronic illness, diabetes,

Question 23

things to consider before bathing (what you always forget)

Answer 23

is there a patient order, is the patient able to take care of themselves, are they bedridden.

Question 24

some patients don’t have the oxygen stores or energy stores for a

Answer 24

bed bath. You need to assess the patient.

Question 25

tub or shower is..

Answer 25

most ideal for bathing, but there might be contraindications.

Question 26

If a patient can shower independently, you need to

Answer 26

escort them to shower, show them where emergency call light is

Question 27

bag bath

Answer 27

some in warmer or heated up in special microwave. Some you can add the warm water.

Question 28

evidence based practice tells us that

Answer 28

prepacked baths are preferred bc the studies show lower risk of healthcare infection, decrease microbial count, nurses prefer it bc it's fast, no reservoir of water in basin, cost of towels and basins, etc.

Question 29

in prepacked baths, make sure you get

Answer 29

every inch of skin on patient

Question 30

hair and scalp care

Answer 30

wear gloves bc of the risk of contact w/ something you don't see. Like breakdown in occipital area.

Question 31

back rub after

Answer 31

bathing, and apply lotion. You need to review for contraindications before, blood clotting for example.

Question 32

with foot inspections, often breakdown is observed..

Answer 32

in between toes.

Question 33

if teeth aren't cleaned every 2 hours for unconscious patient, they develop

Answer 33

aspiration pneumonia. saliva pools and collects bacteria, they breathe it in.

Question 34

toothette

Answer 34

lollipop

Question 35

always remove dentures and inspect for

Answer 35

ulcerations. inspect the gums and clean dentures.

Question 36

if you have a patient who has oxygen, hearing aid, tube feeding...

Answer 36

check where the contact is to make sure no breakdown.

Question 37

hold all contaminated materials..

Answer 37

away from you. Open door with elbow.

Question 38

make sure the bed is..

Answer 38

in the lowest position

Question 39

make sure the bed position is...

Answer 39

safe for the patient

Question 40

make sure the bed controls are

Answer 40

functioning (bed is electrically safe)

Question 41

make sure call light

Answer 41

is functioning and always within reach

Question 42

make sure side rails are

Answer 42

raised if indicated

Question 43

make sure the wheel or casters are

Answer 43

locked

Question 44

infection cycle, or chain of infection. every piece needs...

Answer 44

to be intact to spread infection

Question 45

in infection, first you need

Answer 45

an infectious agent or pathogen. Could be resident or transient pathogen.

Question 46

resident pathogen - and how to remove it

Answer 46

something that is embedded in the skin and requires vigorous friction and antimcrobial soaps to remove.

Question 47

transient pathogen

Answer 47

you can pick it up, easily removed by hand hygiene or hand washing. if you don't, then they will become resident pathogens. Could be part of your normal flora.

Question 48

bacteria can be transmitted even if...

Answer 48

the patient is not infected.

Question 49

people who carry bacteria without evidence of infection (fever, increased wbc) are

Answer 49

colonized

Question 50

if an infection develops, it is usually from (the colony always infects us)

Answer 50

bacteria that colonize patients

Question 51

bacteria that colonize patients can be transmitted

Answer 51

from one patient to another by the hands of healthcare workers

Question 52

reservoir (and ex.)

Answer 52

where an organism will thrive and survive, but not necessarily multiply - could be an inanamate object, fomite. food - salmonella in potato salad. healthcare workers hands, nebulizer.

Question 53

nebulizers have what bacteria? (nebulize pseudos)

Answer 53

pseudomonas.

Question 54

portal of exit

Answer 54

mouth, wound,

Question 55

modes of transmission - what are the most common? (not airborne, etc)

Answer 55

contact. direct contact (handshake) indirect contact - stethascope

Question 56

pneumonia - droplet - what precautions?

Answer 56

surgical mask would be acceptable. if you're within 6 feet of patient, wear a mask

Question 57

airborne - examples of viruses (VCT - vctors in the air) REMEMBER THIS (and what do you need to wear)

Answer 57

TB, Covid, varicella - need to wear an N95 and negative pressure room.

Question 58

chains of infection - you need a...

Answer 58

susceptible host. take care with immunocompromised.

Question 59

we can decrease our susceptibility of infection by..

Answer 59

getting vaccines.

Question 60

if fire, RACE

Answer 60

Rescue anyone in immediate danger Activate the fire code system and notify the appropriate person Confine the fire by closing doors and windows Evacuate patients and other people to a safe area

Question 61

restraints (#1 most important)

Answer 61

1) determine need 2) secure order 3) hand hygiene and PPE 4) id patient 5) explain reason for restraint 6) include patient family 7) choose least restrictive restraint, pad bony prominences, wrap restraint around extremity 8) secure in place w/ velcro etc. 9) 2 fingers under strap 10) use quick release knot on bedframe 11) perform hand hygiene 12) check on patient every hour 13) remove restraint every 2 hours

Question 62

ISBAR

Answer 62

I - intro - Amanda, nursing student S - calling about ellen scheduled for surgery. She's having doubts. B - admitted yesterday, positive for cancer. A - more than just gitters R - should I hold the pre-op? R - I understand you want me to hold the pre-op meds.

Question 63

SOAPIE (soap is subjective)

Answer 63

subjective, objective, assessment, plan, implement, evaluate

Question 64

I in ISBAR

Answer 64

I—Introduction: People involved in the handoff identify themselves, their roles, and their jobs

Question 65

B in ISBAR (what it entails)

Answer 65

B—Background: Vital signs, mental and code status, list of medications, and lab results

Question 66

S in ISBAR

Answer 66

S—Situation: Complaint, diagnosis, treatment plan, and patient’s wants and needs

Question 67

A in ISBAR

Answer 67

A—Assessment: Current provider’s assessment of the situation

Question 68

R in ISBAR

Answer 68

R—Recommendation: Identify pending lab results and what needs to be done over the next few hours and other recommendations for care

Question 69

most common HAI

Answer 69

Catheter associated urinary tract infections (CAUTI)

Question 70

CDC tier I and II

Answer 70

tier 1 - hand hygiene, ppe, don't recap needles, etc tier 2 - airborne, droplet, contact with MRSA