vSIM Flashcards
The nurse is providing training to the staff in a hospital setting regarding the prevention of health care associated infections (HAIs). The nurse identifies which of the following categories as being responsible for the majority of HAIs in the acute care hospital setting? (Select all that apply.)
Catheter associated urinary tract infection, Surgical site infection, Central line associated bloodstream infection, Ventilator associated pneumonia
Rationale:
Based on the premise that most HAIs are preventable, the HAI action plan published by the Centers for Disease Control and Prevention (CDC) includes the following as being responsible for the majority of all infections acquired in the health care setting: catheter associated urinary tract infections, surgical site infections, central line-associated bloodstream infections, and ventilator associated pneumonia. Gastrointestinal infections are not considered to be responsible for a large number of HAIs.
Which intervention(s) will the nurse implement when maintaining medical asepsis? (Select all that apply.)
Practice good hand hygiene., Clean the least soiled areas first., Keep personal fingernails short., Do not place soiled bed linen on the floor.
Rationale:
Medical asepsis techniques are used continuously both within and outside health facilities, based on the assumption that pathogens are likely to be present. Nearly every nursing activity includes practices of medical asepsis. Principles of medical asepsis include good hand hygiene; keeping nails short; cleaning from least soiled to most soiled; and never placing contaminated items on the floor (which would cause contamination to spread). Allowing only sterile items to be touched by sterile items is a principle of surgical asepsis.
When considering a 40-year-old postoperative patient, which factor is likely to present the greatest risk for the development of an infection?
Invasive or indwelling medical procedures or devices
Rationale:
The use of invasive or indwelling medical devices provides exposure to and entry for potential sources of disease-producing organisms. This is particularly risky in immunosuppressed clients or those with weakened defenses due to disease or trauma, such as surgery. The pH levels of the gastrointestinal and genitourinary tracts help to ward off microbial invasion and are therefore important for infection prevention. The white blood cells provide resistance to certain pathogens. The patient’s age, gender, race, and weight influence susceptibility to infection; however, they would not pose the greatest risk.
When bathing a patient who requires contact and droplet precautions, which personal protective equipment (PPE) will the nurse put on? (Select all that apply.)
Gloves, Gown, Mask
Rationale:
Droplet precautions are used for patients with an infection that is spread by large-particle droplets, such as rubella, mumps, diphtheria, and the adenovirus infection in infants and young children. Contact precautions are intended to prevent transmission of infectious agents that are spread by direct or indirect contact with the patient or the patient’s environment. In many cases, such as with the novel coronavirus, the CDC will recommend both droplet and contact precautions be followed. Gloves, gown, and mask are the necessary PPE to wear when contact and droplet precautions have been ordered. HEPA respirators are required when airborne precautions are required. Goggles are needed when there is a risk of splatter of blood or body fluids into the eyes of the caregiver.
The nurse is caring for a patient who has been diagnosed with an infection. The nurse identifies which of the following stages of infection as posing the greatest risk to others?
Prodromal
Rationale:
A person is most infectious during the prodromal stage. During this stage, early signs and symptoms of the disease are present, but these are often vague and nonspecific. The incubation period is the interval between the pathogen’s invasion of the body and the appearance of symptoms of infection. During this stage, the organisms are growing and multiplying, but they may not be readily apparent. The presence of infection-specific signs and symptoms indicates the full stage of illness. During this stage, patients are more fully aware of their infectious status and methods to use to prevent exposure to others. The convalescent period involves the recovery from the infection.
Which intervention(s) will help minimize the risk of infection postoperatively? (Select all that apply.)
Implementing standard precautions, Maintaining hydration, Assessing temperature frequently, Following aseptic technique when changing incision dressings
Rationale:
Nursing interventions to prevent postoperative infection include assessing vital signs for increase in temperature or changes in pulse or respiratory rate; maintaining hydration; maintaining nutritional status; encouraging a diet high in proteins, carbohydrates, calories, and vitamins; implementing standard precautions, including proper hand hygiene; and following aseptic technique when changing dressings at the surgical site and exit sites for tubes and drains. Although pain management is important, it does not influence infection prevention.
The nurse is conducting a neurovascular assessment on a postoperative knee replacement patient. Which assessment data could be considered an initial indication of neurological impairment?
Patient reports ‘pins and needles’ sensation below the incision site.
Rationale:
Paresthesia, often described as a sensation of ‘pins and needles,’ may be the first symptom of changes in sensory nerves to appear. This finding requires further assessment both above and below the affected area. While the other options may indicate neurological impairment, they may be a result of other factors and are not usually the initial indicator of neurological impairment.
The nurse is caring for a patient the day after invasive surgery. The nurse is aware that review of which of the following should be included when assessing for the presence of a systemic infection? (Select all that apply.)
White blood cell count, Body temperature
Rationale:
Nursing assessments include observing for signs and symptoms of a local or systemic infection. Manifestations of a systemic infection include fever and increased white blood cell count. Redness, swelling, and pain, or the presence of bacteria in a wound culture, indicate a local infection but do not confirm the presence of a systemic infection. Blood pressure is not a reliable indication of infection.
The nurse is conducting a neurovascular assessment on a postoperative patient who experienced a total knee arthroplasty (TKA). What initial intervention(s) should be performed by the nurse when it appears that there is an absence of a pulse in the affected foot? (Select all that apply.)
Assess for paresthesia in the affected extremity., Assess the capillary refill and skin color in both lower extremities., Assess the peripheral pulses in both lower extremities.
Rationale:
Assess capillary refill and skin color, comparing the findings of both extremities in order to evaluate arterial blood flow. Assess affected extremity for the presence of paresthesia, which may indicate reduced neurovascular competence. Evaluate comparative peripheral pulses in both extremities to determine venous blood flow in each. Elevation of the affected extremity is directed toward minimizing edema and encouraging venous return. The nurse should notify the health care provider when all relevant assessment data have been collected.
The nurse caring for Mr. Griffin is assessing for signs and symptoms of infection and recognizes the importance of including which of the following as part of the assessment? (Select all that apply.)
White blood cell count, Temperature, Pain level, Surgical site assessment
Rationale:
Common manifestations of infection include pain, redness, swelling at a surgical site, fever, and an increased white blood cell count. The red blood cell count or range of motion would not provide information helpful in determining the presence of infection.
The nurse is reviewing Mr. Griffin’s diagnostic results and recognizes which findings should be reported to the health care provider immediately? (Select all that apply.)
WBC 19,000/µL, Platelets 40,000/µL, Hb 8.5 g/dL
Rationale:
A white blood cell count above normal may indicate the presence of infection. A platelet count below 50,000/µL can cause spontaneous bleeding; when the count is below 5,000/µL, fatal central nervous system bleeding or massive gastrointestinal hemorrhage is possible. A lower than normal hemoglobin may be expected after invasive surgery; however, this finding may also represent internal bleeding or other complications that should be evaluated further. A high RBC count (>5.3 million/µL) may indicate absolute or relative polycythemia. Calcium levels above 10.2 mg/dL are seen in hypercalcemia. The normal values for hematocrit in an adult male fall between 42% and 52%.
The nurse caring for Mr. Griffin understands which of the following nursing interventions will have the greatest impact on minimizing the spread of methicillin-resistant Staphylococcus aureus (MRSA) to other clients on a surgical unit? (Select all that apply.)
Instituting meticulous handwashing technique, Implementing contact precautions, Using appropriate personal protective equipment (PPE)
Rationale:
The nurse can minimize the spread of MRSA by implementing effective handwashing techniques and contact precautions, and by using appropriate PPE. Monitoring cultures and administering antibiotics are appropriate nursing interventions, but they are related to the treatment of existing MRSA, not to preventing the spread of MRSA. Family members should be permitted to visit, provided they follow precautions.
The nurse caring for Mr. Griffin identifies which of the following as priority nursing actions when caring for a client under contact precautions? (Select all that apply.)
Performing hand hygiene, Putting on gown, Donning gloves, Isolating client care equipment
Rationale:
Hand washing, gowning, and gloving are necessary for contact isolation protection. It is important to avoid sharing client care equipment. The mask is appropriate for airborne or droplet precautions. Eye protection is needed if splashing is a risk.
The nurse is completing a postarthroplasty focused assessment on Mr. Griffin to determine musculoskeletal and neurovascular status. Which of the following would be included in this assessment? (Select all that apply.)
Skin color, Skin temperature, Capillary refill, Pedal pulses, Toe movement, Range of motion, Muscle strength
Rationale:
A focused musculoskeletal and neurovascular assessment for Mr. Griffin would include range of motion and muscle strength, as well as skin color, temperature, capillary refill, pedal pulses, and toe movement. These assessments would be performed bilaterally to determine differences between the affected and unaffected side.
The nurse provides client education regarding range of motion exercises to Mr. Griffin in preparation for his pending discharge home. The nurse recognizes that Mr. Griffin understands the information provided when he states which of the following? (Select all that apply.)
‘Range of motion exercises should be performed slowly and gently.’, ‘I should perform range of motion exercises on both sides.’, ‘It may be necessary to continue physical therapy after going home.’, ‘I will need to use a walker or crutches after discharge.’
Rationale:
Postoperative range of motion exercises are an important part of client rehabilitation after total knee arthroplasty. These exercises should be performed slowly and gently to avoid injury and limit pain. They should be performed on both sides to increase range of motion and strength. Physical therapy is commonly required after discharge. Regular range of motion exercises and movement promote healing and increase long-term function. Clients should utilize an assistive device such as a walker, cane, or crutches to slowly increase weight bearing over time and avoid injury. Adequate pain control is essential to a successful exercise program.
