Quiz 3 Flashcards

1
Q

What are the modes of transmission?

A

contact (direct and Indirect)
droplet
airborne
vector borne

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2
Q

What is direct contact and indirect contact?

A

person to person

object to person

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3
Q

How are droplets transmitted?

A

sneezing, coughing, talking

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4
Q

How is airborne transmitted?

A

sneezing, coughing

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5
Q

How is vector borne transmitted ?

A

With animals or insects as intermediaries

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6
Q

How often should hand hygiene be done?

A

always

before, after, in between patients

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7
Q

Where is C.diff found? How can a nurse be sure to not get contaminated?

A

found through the stool

wash hands with soap and water

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8
Q

What are expected findings in the assessment of generalized or systemic infection?

A

fever
increased pulse and resp. rate
fatigue
enlarged lymph nodes

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9
Q

What is the difference between localized and systemic infection?

A

localized: only one part of body or organ

systemic: within the bloodstream

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10
Q

What is inflammation?

A

body’s local response to injury or infection

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11
Q

What are the manifestations localized inflammatory response? What should the nurse do?

A

heat
redness
swelling
pain
loss of function

do not ignore, intervene

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12
Q

What are standard precautions?

A

precautions against body fluids, non-intact skin, and mucous membranes

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13
Q

What do standard precautions require?

A

hand hygiene
- soap and water (spores and C.diff)
- antimicrobial soap (blood, body fluids)
- alcohol (microorganisms)

eye protections

clean gloves

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14
Q

What are airborne precautions?

A

precautions against droplet infections

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15
Q

What do airborne precautions require?

A
  • private room
  • masks
  • negative pressure airflow exchange in room
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16
Q

What are droplet precautions?

A

precautions against droplets that can travel 3ft - 6ft

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17
Q

What do droplet precautions require?

A
  • private room or room with other patients who have same disease
  • masks
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18
Q

What is the order of donning PPE?

A

don
- gown
- mask
- goggles
- gloves

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19
Q

What is the order of doffing PPE? Why?

A

doff
- gloves
- goggles
- gown
- mask
- hand hygiene

remove the dirtiest first

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20
Q

Define cleaning

A

removal of organic/inorganic materials

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21
Q

Define disinfection

A

elimination of microorganisms except bacterial spores

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22
Q

Define sterilization

A

complete elimination of microorganisms, including spores

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23
Q

What should a nurse do to ensure safety for the patient?

A

assess client and their environment

hourly rounding

handoff communication @ bedside

ISBARR

Rapid Response Team

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24
Q

If an injury occurs with a patient or a visitor, what should the nurse do?

A

incident report
- only state facts and what you saw

assess the patient, take vital signs, and see level or harm

notify provider, charge nurse, supervisor

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25
Q

What should you do if you stick yourself with a needle?

A

first wash the area with soap and water, then let someone know

26
Q

What should you do if you get something in your eye?

A

go to eyewash station

27
Q

How does a nurse keep older clients from picking on their IV/catheter?

A

keep out of sight from client

28
Q

What are the types of unexpected events?

A

near miss
client safety event
sentinel event

29
Q

What is a near miss event?

A

didn’t happen, but could have happened

30
Q

What is a sentinel event?

A

events that should never happen

31
Q

What are client factors that create a risk for injury?

A
  • developmental level
  • lifestyle choices
  • cognitive, mobility, communication, sensory impairment
  • knowledge of common safety precautions
32
Q

How can a nurse prevent falls?

A

fall risk assessment

put bed/chair alarm for patients who constantly get up

33
Q

Which patients are at higher risk for falls?

A

patients who have to pee a lot and that are mobile

34
Q

Is a patient with a sore on their leg at high risk for falls?

A

no

35
Q

What are some safety precautions for older clients in hospital at night?

A

night light
no loose rugs or cords
rails in bathroom to assist

36
Q

Which patients should be put closer to the nurses station?

A

high risk
confused
paralyzed
seizures

37
Q

What are restraints used for? Do they require a provider’s order?

A

to protect patient and staff from harm when least restrictive measures do not work

yes

38
Q

What should restraints not be used for?

A
  • convenience of staff
  • punishment of client
  • clients who are are physically/mentally unstable
39
Q

What should restraints do?

A
  • never interfere with treatment
  • restrict movement as little as necessary
  • fit properly
  • be discreet
  • be easy to remove
40
Q

Why do restraints have padding for the bony prominences?

A

to prevent injuries

41
Q

Why is a quick release knot done for restraints?

A

for emergency situations

42
Q

What least restrictive measures should be done before restraints?

A
  • get pt a sitter
  • encourage family to stay
  • provide distractions
  • reorient them
43
Q

What is the fire response following the RACE sequence?

A

Rescue: patients first

Alarm: fire alarm

Contain: fire, shut off any sources of oxygen, close doors

Extinguish: fire extinguisher

44
Q

How do you use a fire extinguisher?

A

PASS

Pull
Aim
Squeeze
Sweep

45
Q

What is an EHR?

A

electronic health record

overall

46
Q

What is an EMR?

A

electronic medication record

single visit

47
Q

Why is documentation in a chart/medical record important?

A

it is the legal record of care

shows facts

can compare to baseline data

48
Q

What are the different formats of documentation?

A

flowcharts
narrative
problem-oriented
SOAP
SOAPIE
PIE
Focus charting (DAR)
charting by exception

49
Q

What are flowcharts?

A

assessments

50
Q

What is narrative documentation?

A

sequence of events

51
Q

What is problem-oriented documentation?

A

organized by problem/diagnosis

52
Q

What is SOAP documentation?

A

subjective
objective
assessment
plan

53
Q

What is SOAPIE documentation?

A

subjective
objective
assessment
plan
intervention
evaluation

54
Q

What is PIE documentation?

A

problem
intervention
evaluation

55
Q

What is focus charting (DAR) documentation?

A

data
action
review

56
Q

What is charting by exception documentation?

A

focuses on documenting deviations

57
Q

If a nurse is going to give medication for pain, what should they do?

A
  • assess
  • document pt pain level from scale of 1-10
  • give medication and document

reassess pain after

58
Q

If a patient is not breathing well, what should the nurse do first?

A

put the head of the bed up

59
Q

If a patient is connected to oxygen, what should a nurse do for their safety?

A

make sure they do not use anything electric or combustible

60
Q

What should be documented for a wound dressing?

A

appearance of drainage
odor
discharge
type of dressing used
sterile or aseptic

61
Q

What should be documented when taking vital signs?

A

location (specific site)
how it was taken
machines used

62
Q

What do vital signs include?

A

BP
HR
O2
Pain assessment
Temp
Pulse
Respirations