NUR 222 ATI Flashcards
(54 cards)
A nurse is about to irrigate an open wound. besides gloves, which of the following personal protective equipment should the nurse wear?
A face shield
A nurse is washing their hands with soap and water prior to repositioning a client in bed. During the handwashing procedure, it is important to take one of the following actions?
wash hands for at least 20 seconds
A nurse is caring for a client who has a health care-associated infection (HAI). Which of the following describes an exogenous HAI?
A Salmonella infection that occurs after eating contaminated food from the cafeteria
Antimicrobial soap and water?
After washing hands with antimicrobial soap and water, no residual material remains on the hands to affect the permeability of latex gloves.
Alcohol-based antiseptic gel
Using alcohol-based antiseptic gel is a recommended practice prior to the donning of gloves. This type of product does not affect the integrity of latex gloves.
Petroleum-based hand lotion
The use of petroleum-based hand lotions or creams can impair the integrity of latex gloves, weakening them and increasing their permeability.
How long can influenza viruses survive outside a host?
At room temp, with moderate humity, these viruses can live until 24-48 hours on steel and plastic and 8 -12 on cloth and facial tissies
Tertiary
The nurse is demonstrating tertiary prevention. Tertiary prevention is providing care to control a health condition. By administering insulin to the client, the nurse is assisting with managing the client’s type 1 diabetes mellitus.
Quaternary
Quaternary prevention is protecting a client from care that is excessive or might cause harm, such as medications or treatments that are unnecessary.
Primary
Primary prevention is providing care to decrease the risk for a health condition. Primary prevention can include modifying behaviors in the client’s lifestyle such as exercise and diet, or immunizations.
Secondary
Secondary prevention is providing care to detect a health condition. Secondary prevention can include screenings for hypertension, hyperlipidemia, or cancer.
Appropriate hand hygiene based on the situation
Single most important procedure for preventing infections
-Wearing gloves does not replace the need for hand washing
-Hand hygiene- before & after each patient contact/environment, after
removing gloves
-Wash instead of gel- when hands are visibly soiled, after contact with bodily
fluids, before eating, after bathroom, exposure to organism (c. diff)
-Can use gel when- hands are not visibly soiled, entering/exiting rooms of
patients, before touching each patient with or without gloves, after touching
patient, after glove removal, after blowing nose, after coughing, after sneezing
Describe basic principles and precautions to prevent transmission of disease
Control or eliminate the agent
Identify and treat the organism
Control the reservoir
Control the portal of exit drain wounds, respiratory tract, body fluids
Control transmission as hand washing, and isolation techniques
Control entry such as maintaining and skin and membranes by washing hands
Demonstrate the use (including donning and doffing) of Personally Protective equipment PPE
-don- gown, mask, goggles, gloves
-doff- gloves, googles, gown, mask
Recognize PPE necessary based on the need for precaution
Airborne- mask (n95, PAPR), door shut always, negative pressure, limit transport (Tb, measles-rubeola, chicken pox-varicella)
transport (Tb, measles-rubeola, chicken pox-varicella)
-droplet: mask (regular), larger drops, private room, (pneumonia, influenza,
German measles-rubella, pertussis)
contact- gown, gloves, wash hands w/ antibacterial soap before leaving the
room, visitors go to station before entering (MRSA – methicillin-resistant
staphylococcus aureus, VRE-vancomycin resistant Enterococcus, lice/scabies,
major draining wounds)
-reverse isolation / neutropenic / protective- mask (regular), no flowers, no
plants, only cooked foods, no salad, no fruits, no vegetables, private room,
mask during transport
Differentiate between restraint types (e.g., application, assessment)
-Used for combative patients, pulling out tubes, resisting care, fall risk
-Can result in injuries, skin breakdown, muscle atrophy, pressure ulcers
-To apply: 1. Pad bony prominences, 2. ensure 2 fingers can be placed between
restraint and patient 3. Perform ROM exercises when removing restraint
-Quick release knot
-If the patient is flat, they are at risk for aspiration and choking
-Mitt: patients pulling tubes
-Gait belt
Understand expectations for restraint orders
-Renew order every 24 hours, assess every hour, remove every 2 hours
Recognize client environment safety hazards and fall prevention measures
-Wrist band
-Call light near by
-Gait belt
-Assistive device
-Bed at lowest position
-Gripper socks
Susceptible host:
influenced by age, nutritional status, stress, disease process,
medical treatment, and hereditary
Aseptic:
absence of pathogenic microorganisms
Medical asepsis:
clean technique – handwashing, clean (nonsterile) gloves
Surgical asepsis:
sterile technique
Assessment and documentation of accurate intake and output
Intake- measurement of any fluid coming into the body
-Liquids- water, milk, etc.; ice cream, Jello, popsicles, pudding, cream cereals,
custard, counts if liquid at room temp -Output: measurement of any fluid coming out of the body, drainage, diarrhea,
urine, emesis
-Normal intake- 2300-2600cc per day
-Normal output- 2300-2600cc per day
Discuss occult stool collect
-Get hemoccult test paper, hemoccult developer, and wooden applicator
