MIDTERM

Question 1

Chain of infection

Answer 1

1. pathogen i.e., common cold virus
2. reservoir i.e., people
3. exit of reservoir i.e., out of mouth via saliva
4. transportation i.e., sneeze/cough, speech, hands…
5. portal of entry i.e., eyes, mucous membranes …
6. susceptible host i.e., anyone

Question 2

routine precaution “standard” and PPE

Answer 2

For ALL patients regardless of diagnosis or presumed infectiousness when handling:
* All body fluids, secretions and excretions except sweat
* Blood
* Non-intact skin
* Mucous membranes
PPE: gloves, gown, mask; eyewear as needed

Question 3

isolation precaution - contact

Answer 3

germs are on surface of patient
PPE: gloves and gown

Question 4

isolation precaution - droplet

Answer 4

germs are in large droplets in air within 1-2 m of patient. germs can survive in environment away from patient.
PPE: gown, gloves, mask, eyewear within 2m of patient

Question 5

isolation precaution - airborne

Answer 5

germs are suspended in tiny air particles
PPE: N95 mask

Question 6

donning

Answer 6

1. hand hygiene
2. gown
3. mask
4. eyewear
5. gloves

Question 7

doffing

Answer 7

1. gloves
2. hand hygiene
3. gown
4. hand hygiene (2m away from patient)
5. eyewear
6. hand hygiene
7. mask
8. exit room and hand hygiene

Question 8

10 risk factors for falls (older adults)

Answer 8

1. change in vision
2. change in hearing
3. change in mobility
4. changes in reflexes
5. genitourinary changes
6. unfamiliar environment
7. uneven/broken pavement
8. medications
9. dizziness and vertigo
10. postural instability

Question 9

Henrich II Fall Risk Model

Answer 9

used to determine potential risks.
score greater than 5 = high risk of falling

Question 10

10 ways to prevent falls as a nurse

Answer 10

1. using Henrich II Fall Risk Model
2. call bell instruction
3. fitted shoes for patient
4. uniform stair sizes
5. proper lighting
6. proper handrails
7. elevated toilet seat with armrests
8. secure power cords along baseboard
9. supervising patients who are confused
10. placing tables near patients to avoid reaching over

Question 11

5 SAFTEY CHECKS

Answer 11

1. braked are on
2. bed is in lowest position
3. call bell is in reach
4. side bars/ rails are up as needed
5. personal belongings are in reach

Question 12

seizure

Answer 12

• close curtain for privacy
  before : pillows on bed and available,
  position bed low, 2 side rails up, padded
  side-rails and headboard (if possible)
  during : ensure safety of environment, put
  pillow under head, do not put anything in
  their mouth, put bed rails up with padding,
  provide privacy, if able – turn patient to
  side-lying position, loosen tight clothing
  (ties, strings etc.), time the seizure

Question 13

sleep protocol

Answer 13

1. reduce the amount of noise i.e., close doors/ windows
2. dim lights
3. announcement on PA that sleep will commence soon and minimize noise
4. turn on white noise machine
5. round for quietness - ask patient if they would like eye mask/ earplugs

Question 14

deconditioning - metabolic/ gastrointestinal

Answer 14

• peristalsis decreases, fluid intake and appetite decrease
• difficulty passing stool
• edema
• electrolyte imbalance - calcium

Question 15

respiratory

Answer 15

• decreased lung expansion and a decrease in gas exchange
• pulmonary secretions begin to pool
• atelectasis = collapse of alveoli

Question 16

cardiovascular

Answer 16

• decreased cardiac output
• orthostatic hypotension = drop in BP
• heart works faster and less efficiently
• thrombus = materials attach to the inside of a vein
• embolus = a dislodged thrombus that travels through the circulatory/ respiratory system

Question 17

musculoskeletal

Answer 17

• reduced muscle mass and impaired joint mobility
• decreased endurance as the patient
  osteoporosis = loss of bone mass
  joint contracture = fixation of a joint
  foot drop = inability to dorsiflex due to nerve damage

Question 18

urinary elimination

Answer 18

kidneys and ureters are at a level position, urine must enter ureters unassisted by gravity
- increased rate of UTIs and renal calculi

Question 19

intergumentary

Answer 19

increased risk for pressure injuries
- prolonged ischemia (decreased flood flow) can result in a pressure injury
- inflammation over a bony prominence ex. scapulae, elbows, coccyx, heels

Question 20

ROM

Answer 20

done to prevent joint contracture and reducing hazards of immobility
- active = patient does it
- passive = nurse moves each joint

Question 21

pressure ulcer development - pressure intensity

Answer 21

minimal pressure required to collapse capillary. tissue ischemia or reduction of blood flow can occur when there is a prolonged period

Question 22

pressure ulcer development - pressure duration

Answer 22

low pressure over a long period of time and high intensity pressures over short periods of times both cause tissue damage
- extended periods of time can occlude blood flow and nutrients, contributes to cell death

Question 23

pressure ulcer development - tissue intolerance

Answer 23

the ability of tissue to endure pressure depends on the integrity of the tissue and the supporting structure
- factor of shear, friction, and moisture affect the skins ability to tolerate pressure

Question 24

why are older adults at risk for pressure injuries (4)

Answer 24

1. impaired mobility
2. impaired sensory perception
3. alteration in level of consciousness
4. nutrition

Question 25

5 classic signs of wound infection

Answer 25

1. erythema (redness) or edema (swelling) 2. warmth in surrounding tissue 3. pain/tenderness 4. purulent discharge 5. fever/chills

Question 26

body mechanics

Answer 26

1. tighten abdominal muscles. keep back , neck, pelvis, and feet aligned. avoid twisting 2. bend at knees and keep feet apart, lower center of gravity 3. use your arms and legs, NOT your back 4. slide patient toward your body 5. person with heaviest load coordinates the effort by counting to three

Question 27

Braden Risk Assessment

Answer 27

to determine the patients level of pressure injury risk - smaller the number = the more at risk

Question 28

fowler's

Answer 28

head of bed raised to 45* or more - semi-sitting position, foot of bed raised at knee used: when patient eats or nasogastric tube insertion and nasotracheal suction\ promotes lung expansion

Question 29

semi-fowler's

Answer 29

head raised approx. 30*, foot of bed raised at knee - promotes lung expansion Use: patient receives gastric feedings to reduce regurgitation and aspiration

Question 30

trendelenburg's

Answer 30

entire bed frame tilted downward use : postural drainage facilitates venous return in patients who have poor peripheral perfusion

Question 31

reverse trandelenburg's

Answer 31

entire bed frame is tiled up used infrequently - promotes gastric emptying (gravity) and prevents esophageal reflux

Question 32

flat

Answer 32

horizontally parallel with floor use : patients with vertebral injuries and in cervical traction. if patients are hypotensive (low BP) and for sleeping

Question 33

body mechanics in bed making

Answer 33

1. bed should be raised to appropriate height 2. nurse should move back and forth to opposite sides of the bed, no reaching over 3. turning or repositioning the patient, side rails up on the side the patient will face

Question 34

supported supine position

Answer 34

- rolled towel in lumbar area to support the spine - pillow under patients upper shoulders, neck, or head to retain proper alignment - trochanter rolls or sandbags parallel to the lateral surface of the patients thighs if immobile - heel boots to prevent foot drop - pillows under pronated forearms, keeping upper arms parallel to body - hand roles in patients hands to prevent extension of fingers and abduction of thumb

Question 35

Sabina

Answer 35

sit to stand to sit orange sling = medium unlock brakes on sabina -make sure brakes are locked on commode or wheelchair step 1 : position sling around hips/lower back, secure buckle and tighten waist belt. step 2 : feet flat on foot step (shoes), position elbows around the sling patients arms either flat against body or holding onto straps

Question 36

golvo

Answer 36

patient is non weight bearing supine to sitting - Place the sling under the client – ensure shoulders are supported and the lower edge of the sling is at the top of the sacrum /buttocks and top of sling (with head support) covers client’s head.

Question 37

ceiling lift - universal

Answer 37

supine to sitting - transfer patient from bed to wheelchair/ commode/ OR bedside chair neck support - good for patients with poor neck control bar is perpendicular

Question 38

ceiling lift - positioning sling

Answer 38

moves in supine bar is parallel move pillow to head to bed to prevent bonking

Question 39

hygiene sling

Answer 39

used to lower patient directly into bathtub supine to 90*

Question 40

escar

Answer 40

unstageable - can't see what's under it