Download NURS 221 Test Review: Comprehensive Q&A on Hygiene, Mobility, and Infection Control and more Exams Advanced Education in PDF only on Docsity!
NURS 2 21 TEST REVIEW BY LATASHA 3 EXAM WITH COMPLETE
SOLUTIONS 1 00 % VERIFIED!!
Why is hygiene important? - ANSWER It is necessary for comfort, safety, ad well-being
What should you consider when giving a patient a bed bath? - ANSWER normal grooming routines, culture, and individualize care
Therapeutic baths - ANSWER used to promote comfort and/ or provide treatment, such as soothe itchy skin
Partial baths - ANSWER are useful when tolerate clients cannot tolerate a complete bath, need particular cleansing of odorous or uncomfortable are, or can perform part of the bath by themselves
Complete bath - ANSWER you can give a complete bed bath to a patient who can tolerate it and whose hygiene needs warrant it
Chlorhexdine gluconate (CHG) bath - ANSWER Uses antimicrobial bath wipes to decrease the frequency of hospital-acquired infection to the skin
Bag bath - ANSWER contains several, soft non woven cotton cloths that are premoistened in a solutin of a no-rinse surfactant cleasnser
What are the basics of performing bed bath? - ANSWER Provide privacy
Maintain safety
Maintain warmth
Promote independence
Anticipate needs
When is a back rub usually given? - ANSWER After the patient's bath
The goal is to promote relaxation and relieve muscle tension
Effleurage- long, slow, gliding strokes of a masage
Perineal care - ANSWER must be performed at least once a day and maybe more if the patient has a urinary catheter
What patient population in need of perineal care are at a great risk for infection? - ANSWER uncircumcised males, patients who have indwelling urinary catheters, those who are recovering from rectal/genitla surgery, and childbirth
T/F: CHG is safe to use on the perineum for cleansing - ANSWER True
What might cause changes in the oral cavity? - ANSWER Xerostomia-dry mouth
Gingivitis-inflammation of the gums
Dental caries-tooth decay
Why is oral hygiene important? - ANSWER It helps to prevent and control plaque-associate oral diseases
What can impair salivary secretion? - ANSWER Medications
Exposure to radiation
Mouth breathing
Brushing - ANSWER Educate your patients not to share toothbrushes, change their toothbrush every 3 months or following a cold, not to use mouthwash under the age of 6 to reduce the risk of shallowing it
In the diet of someone who has osteoporosis what should you be assessing for? - ANSWER Calcium and Vitamin D
Screening for osteoporosis begins with _______ - ANSWER middle aged adults.
What is the goal of a patient who has osteoporosis? - ANSWER To maintain independence with ADLs
Teaching patients with Osteoporosis - ANSWER Educate the family/caregiver about common risk factors and how to modify lifestyle
Teach patient and/or caregiver the recommended dietary allowance for calcium and vitamin D ( leafy greens, yogurt, cheese)
Instruct in appropriate weight-bearing exercises
Teach about safety, fall prevention, and strategies to create a safe home environment
Cultural Influences on mobility - ANSWER Certain culture discourage involvement in organized recreational physical actives such as basketball, running, and aerobics
Ethnic dancing is an effective activity that is acceptable in many countries
Other cultures emphasize exercise in terms of actives of daily living such as walking or gardening
SCD - ANSWER are use to prevent blood clots in the lower extremities
they consist on sleeves that are wrapped around the patients leg and are inflated with pressure on average of 40 mm Hg
The pressure is added in cycles of inflation for 10 to 15 seconds, deflation for 45 to 60 seconds
TED hose aka elastic stockings - ANSWER maintain external pressure on the muscles of the lower extremities
promote blood return to the heart
you do not want to apply them if the patient has a local condition affecting their legs
For SCD's, the back of patients ____ should line up with inner lining of sleeve - ANSWER Ankle
What is important with SCDS and knee placement? - ANSWER There should be a popliteal opening.
Compression stocking should be removed how often? - ANSWER Once every shift
What should you do with patient who are immobile to help them avoid blood clots? - ANSWER Perform leg exercises, increase fluid intake, change positions frequently
What is a physiologic outcome of someone who is immobile? - ANSWER Decreased lung expansion
What are examples of safe transfers? - ANSWER from bed to chair, and from bed to stretcher
What are some positions to put patient in who are immobile? - ANSWER Fowler's, supine, prone, side-lying, and Sim's position
When addressing needs and preventing complications in an immobilized client what do you look for? - ANSWER repositioning needs, movement exercises (ankle pumps, foot circles, and knee flexion), providing adequate hydration, serve a diet rich in fluids, fruits, vegetables, and fiber, and skin assessments
What are Body Mechanics? - ANSWER Coordinated efforts of the musculoskeletal and nervous systems
What does body mechanics and alignment also refer to? - ANSWER posture,
susceptible host
What are the stages of an infection? - ANSWER Incubation: internal between the pathogen entering the body and the presentation of the first symptom
Prodromal: interval from onset of general symptoms to more distinct symptoms. During this time, the pathogen is multiplying
Illness: internal when symptoms specific to the infection occur
Convalescence: interval when acute symptoms disappear. Total recovery could take days to months
what is included in full thickness wound repair? - ANSWER hemostasis, inflammatory phase, proliferative phase, and remodeling
What are two methods to classify skin wounds? - ANSWER healing by primary or secondary intention, and wound repair by partial thickness or full thickness wound repair
What do you look for in wound appearance? - ANSWER color, length, width, depth, tunneling, edema, drains, wound closures, palpate the wound, and wound culturing
How do you prepare a client for a dressing change? - ANSWER evaluate the pain, describe procedure steps, gather supplies, recognize normal signs of healing, answer questions about the procedure or wound
During a dressing change what do you do? - ANSWER assess the skin beneath the tape, perform thorough hand hygiene before and after wound care, wear sterile gloves before directly touching an open or fresh wound, remove or change dressing over closed wounds when they become wet or if the patient has signs or symptoms of infection and as ordered
When packing a wound you... - ANSWER assess size, depth, and shape
when securing a wound use.. - ANSWER tape, ties, or binders
To provide the most comfort for the patient you would want to what? - ANSWER carefully remove tape, gently clean the wound, and administer analgesics before dressing change
What are some dressing types? - ANSWER dry or moist, film dressing, hydrocolloid, hydrogel, and wound vacuum assisted closures
Hydrocolloid - ANSWER maintains moist granulating wound bed, can be left on up to seven days
Hydrogel - ANSWER Aquasorb. Maintsins a moist surface to support healing for infected, deep wounds, necrosis, moist, may stay in place up to 3 days
what is a hydrocolloid dressing made of? - ANSWER gel and pectin
Transparent film dressing - ANSWER Ideal for small superficial wounds, partial thickness wounds to protect high risk skin
what is a hydrogel dressing made of? - ANSWER mostly water
Wound vacuum assisted closure - ANSWER V.A.C. Uses negative pressure to support healing
What are the stages of pressure ulcers? - ANSWER Stage I: The skin is intact with nonblanchable redness of a localized are.Discoloration of the skin, warmth, edema, hardness, or pain might be present
Stage II: ulcer is visible with reddish-pinkish bed without slough or bruising
Stage III: bone, tendon, and muscle are not exposed but fat maybe loss
Stage IV: In full-thickness tissue loss with exposed bone, tendon, muscle, and
Goggles
Gown
Mask
what are the Principles of sterile technique? - ANSWER a sterile object remains sterile only when touched by another sterile object; only sterile objects may be placed on a sterile field; a sterile object or field out of the range of vision or an object below a person's waist is contaminated; a sterile object or field becomes contaminated by prolonged exposure to air; when a sterile surface comes in contact with a wet, contaminated surface, the sterile object becomes contaminated by capillary action; fluid flows in the direction of gravity; the edges of a sterile field or container are considered to be contaminated
What is the importance of and principles r/t hand hygiene? - ANSWER physical hygiene is necessary for comfort, safety, and well being; ill patients require assistance with personal hygiene; factors such as culture and age influence a patient's hygiene practices; good hygiene techniques promote normal structure and function of tissues; apply knowledge of pathophysiology to provide preventative hygiene care
Airborne precautions - ANSWER Private room
Gown, mask, and Gloves
Negative pressure airflow exchange
List some Airborne precaution diseases - ANSWER Measles
Varicella
Pulmonary or laryngeal TB
Droplet precautions - ANSWER Droplet precautions
Private room
Masks
List of some droplet precaution disease processes - ANSWER Strep pharyngitis or pneumonia
Homophiles flu B
Scarlet fever
Rubella
Pertussis
Mumps
Mycoplasma
Contact precaution - ANSWER Private room
Gloves and gown
Disposal of infection dressing into nonporous bag
Examples of contact precaution disease processes - ANSWER MRSA
Shigella
Wound infection
Herpes simplex
A peron's cane length is _____ - ANSWER to equal to the distance between the greater trochanter and the floor
A person's cane should be used on what side of the body? - ANSWER The strong side
What should the degree of that arm angle be at when using crutches? - ANSWER 30 degrees
What are proper urine specimens? - ANSWER specimen collection from infants and children is difficult; adolescents and school aged children usually are able to cooperate; preschool children and toddlers have difficulty voiding on request; urine testing
What is special about urine collection in adolescents/school aged children? - ANSWER They are usually able to cooperate but be caution of privacy.
What does RACE stand for? - ANSWER rescue, alarm, confine, extinguish
What does PASS stand for? - ANSWER pull the pin, aim, squeeze, sweep
If seizures occur what do you do? - ANSWER always stay with the patient, call for help, if standing, guide to the floor and cradle head in lap or place pad under head, provide privacy, turn patient on side if able with head tilted and slightly forward, do not place anything in mouth, note time seizure starts, ends, and the patients behavior, maintain patent airway, suction, and apply oxygen by nasal cannula
What factors increase risk for falls? - ANSWER Poor Vision
Cognitive dysfunction
Impaired mobility
Urinary frequency
Physical condition
Medications
Age
History of falls
What are fall risks scored by? - ANSWER Morse Fall Risk Assessment
How do you prevent falls? - ANSWER side rails up when appropriate, bed low position/wheels locked, call bell in reach, glasses, hearing aids, ambulatory aids in use, room clutter free, clean up spills, electrical safety good lighting, provide non-skid footwear for clients
Chemical restraints are mainly used in what situation/floor? - ANSWER ICU
_____ restrains may cause confusion to the elderly. - ANSWER Chemical restraints
what do you assess when using restraints? - ANSWER mental status, pain, education level and understanding of client, therapy needed, determine need for restraint
What needs to be determined for a use of a restraint? - ANSWER if behavior may interrupt therapy, or if there is a threat to self or others
what are some safety measures when using restraints? - ANSWER inspect client for injury per policy, check neurological and circulatory status, ensure restraint is secure but not restrictive loose enough for two fingers to fit between restraint, never tie to bed rails (use quick release knot), explain need for restraint to client and family, never leave client alone if restraint is removed temporarily, orders are required, reassess for q 24 hours.
What must you document when using restraints? - ANSWER what behavior required restraint, type of restraint applied, education provided to family/client, clients consent if required policy, times of application and removal, assessment of client, limb, ROM, assessment of therapy, review physician order for changes/updates
Types of enemas - ANSWER Cleansing
Oil retention
Medicated
Carminative
Cleansing enema - ANSWER Stimulate peristalsis. Can be hypotonic tap water, normal saline isotonic, hypertonic, or soapsuds
What is special with children and enemas? - ANSWER Infants and children ONLY receive normal saline because they are at risk for fluid imbalance
