Defenses against infection - Normal flora - Body defense mechanisms - Inflammation - Vascular and cellular responses - Inflammatory exudate - Tissue repair

- Normal flora - Body defense mechanisms - Inflammation - Vascular and cellular responses - Inflammatory exudate - Tissue repair

National Patient Safety Goals - Improve the accuracy of patient identification - Improve the effectiveness of communication among caregivers ◦ EHR ◦ SBAR - Improve the safety of using medications - Medication reconciliation - Fall reduction -Health care-associated infections - Encourage patient involvement in own care -Reduce risk for fires ◦ R.A.C.E -Vaccinations of older adults

- Improve the accuracy of patient identification - Improve the effectiveness of communication among caregivers ◦ EHR ◦ SBAR - Improve the safety of using medications - Medication reconciliation - Fall reduction -Health care-associated infections - Encourage patient involvement in own care -Reduce risk for fires ◦ R.A.C.E -Vaccinations of older adults

Week 1 Flashcards by Sasha K.

Nature of infection

◦ Entry and ____________ of organism result in disease
◦ ________________ occurs when a microorganism invades the host but does not cause infection
◦ _______________ disease is the infectious process transmitted from one person to another

◦ Entry and multiplication of organism result in disease
◦ Colonization occurs when a microorganism invades the host but does not cause infection
◦ Communicable disease is the infectious process transmitted from one person to another

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Infectious processes

Incubation period
Prodromal stage
Illness stage

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Defenses against infection

Normal flora
Body defense mechanisms
Inflammation
Vascular and cellular responses
Inflammatory exudate
Tissue repair

Normal flora
Body defense mechanisms
Inflammation
Vascular and cellular responses
Inflammatory exudate
Tissue repair

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Exogenous infection Vs Endogenous infection

Exogenous- anything outside of the body entering (bacteria, etc)

Endogenous- Ex) C. Diff- normal flora in our gut becomes infectious

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Infection prevention

Assessment includes a through investigation.
◦ Review of past diseases, travel history
◦ Immunizations and vaccinations
◦ Status of defense mechanisms
◦ Client susceptibility
◦ Clinical appearance
◦ Laboratory results

◦ Review of past diseases, travel history
◦ Immunizations and vaccinations
◦ Status of defense mechanisms
◦ Client susceptibility
◦ Clinical appearance
◦ Laboratory results

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Use NANDA-approved diagnoses.
◦ Risk for infection…
◦ Impaired tissue integrity…
◦ Imbalanced nutrition: less than body requirements…

◦ Risk for infection…
◦ Impaired tissue integrity…
◦ Imbalanced nutrition: less than body requirements…

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Identify goals and outcomes.
◦ Preventing exposure…
◦ Controlling or reducing the extent of infection…
◦ Verbalizes understanding of inf. prevention and control…

◦ Preventing exposure…
◦ Controlling or reducing the extent of infection…
◦ Verbalizes understanding of inf. prevention and control…

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Infection

When implementing care, consider:
◦ Medical and surgical asepsis
◦ Control or elimination of infectious agents
◦ Control or elimination of reservoirs
◦ Control of portals of entry
◦ Control of transmission
◦ Hand hygiene
◦ Isolation and isolation precautions

◦ Medical and surgical asepsis
◦ Control or elimination of infectious agents
◦ Control or elimination of reservoirs
◦ Control of portals of entry
◦ Control of transmission
◦ Hand hygiene
◦ Isolation and isolation precautions

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Standard Precautions – for all patients - _______

gloves

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_________ Precautions – private room – negative pressure – airflow – HEPA masks

Airborne

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Droplet Precautions – private room or cohort patients – ______

mask

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________ Precautions – private room or cohort patients, gloves, gowns

Contact

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_________ Environment – Private room, positive pressure airflow – HEPA masks

Protective

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Surgical asepsis or sterile technique:
◦ Prevents ______________ of an open wound
◦ Serves to isolate the operative area from the unsterile environment
◦ Maintains a sterile field for surgery

◦ Prevents contamination of an open wound
◦ Serves to isolate the operative area from the unsterile environment
◦ Maintains a sterile field for surgery

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Infection prevention - Evaluation step

-Measure the ________ of the infection control techniques.
- Compare the client’s actual response with expected ___________.
- If goals are not achieved, determine what steps must be taken.

-Measure the success of the infection control techniques.
- Compare the client’s actual response with expected outcomes.
- If goals are not achieved, determine what steps must be taken.

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Which is the most likely means of transmitting infection between patients?

A. Exposure to another patient’s cough
B. Sharing equipment among patients
C. Disposing of soiled linen in a shared linen bag
D. Contact with a health care worker’s hands.

D. Contact with a health care worker’s hands.

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A patient is isolated for pulmonary TB. The nurse notes that the patient seems to be angry, but he knows that this is a normal response to isolation. Which is the best intervention?

A. Provide a dark, quiet room to calm the patient.
B. Reduce the level of precautions to keep the patient from becoming angry.
C. Explain the reasons for isolation procedures and provide meaningful stimulation.
D. Limit family and other caregiver visits to reduce the risk of spreading the infection.

C. Explain the reasons for isolation procedures and provide meaningful stimulation.

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Mrs. Martin’s son visits her and asks Mary what could have contributed to his mother getting an infection. Mary bases her answer on knowing that Mrs. Martin has a higher risk for developing an infection. What factors make Mrs. Martin more susceptible to infection? Select all that apply.

A. Gender
B. Age
C. Poor nutrition
D. Low blood sugar
E. Stress

Age
Poor nutrition
Stress

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The most important way to prevent infection is :

hand hygiene

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it is acceptable to use alcohol-based waterless hand sanitizers for routine decontamination, except when the hands are:

visibly soiled.

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Risks in Health Care Agency

-Medical errors
-Chemical use
-Falls
-Client-inherent accidents
-Procedure-related accidents
-Equipment-related accidents

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Critical Thinking

In client safety, critical thinking is an ongoing process.

Utilize standards developed by : [2]

American Nurses Association and The Joint Commission.

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National Patient Safety Goals

Improve the accuracy of patient identification
Improve the effectiveness of communication among caregivers
◦ EHR
◦ SBAR
Improve the safety of using medications
Medication reconciliation
Fall reduction
-Health care-associated infections
Encourage patient involvement in own care
-Reduce risk for fires
◦ R.A.C.E
-Vaccinations of older adults

Improve the accuracy of patient identification
Improve the effectiveness of communication among caregivers
◦ EHR
◦ SBAR
Improve the safety of using medications
Medication reconciliation
Fall reduction
-Health care-associated infections
Encourage patient involvement in own care
-Reduce risk for fires
◦ R.A.C.E
-Vaccinations of older adults

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During hygiene assess:

◦ Physical limitations
◦ Health promotion practices and needs
◦ Emotional needs

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Dermal-epidermal junction ◦ Separates :

dermis and epidermis

__________ - Top layer of skin __________ - Inner layer of the skin

Epidermis - Top layer of skin Dermis - Inner layer of the skin

Pressure ulcer ◦ Pressure sore, decubitus ulcer, or bed sore Pathogenesis ◦ Pressure _________ ◦ Pressure ___________ ◦ Tissue __________

◦ Pressure sore, decubitus ulcer, or bed sore Pathogenesis ◦ Pressure intensity ◦ Pressure duration ◦ Tissue tolerance

Risk Factors for Pressure Ulcer Development -Impaired _________ perception -Impaired ___________ -Altered level of _______________ -Shear -Friction -Moisture

-Impaired sensory perception -Impaired mobility -Altered level of consciousness -Shear -Friction -Moisture

Classification of Pressur Ulcers

Prediction and prevention of pressure ulcers ◦ Norton Scale - Physical and mental condition, activity, mobility, and continence ◦ Braden Scale - Sensory perception, moisture, activity, mobility, nutrition, and friction and shear

◦ Norton Scale - Physical and mental condition, activity, mobility, and continence ◦ Braden Scale - Sensory perception, moisture, activity, mobility, nutrition, and friction and shear

Factors Influencing Pressure Ulcer Formation and Wound Healing - Nutrition - Tissue perfusion - Infection - Age - Psychosocial impact of wounds

- Nutrition - Tissue perfusion - Infection - Age - Psychosocial impact of wounds

Skin integrity/wound assessment -Presence of ulcers -Mobility -Nutrition and fluid status -Pain -Existing wounds, appearance, character -Wound culture

-Presence of ulcers -Mobility -Nutrition and fluid status -Pain -Existing wounds, appearance, character -Wound culture

Skin integrity/wound - implementation Health promotion ◦ Topical skin care - Protect bony prominences, skin barriers for incontinence. ◦ Positioning - Turn every 1 to 2 hours as indicated. ◦ Support surfaces - Decrease the amount of pressure exerted over bony prominences.

◦ Topical skin care - Protect bony prominences, skin barriers for incontinence. ◦ Positioning - Turn every 1 to 2 hours as indicated. ◦ Support surfaces - Decrease the amount of pressure exerted over bony prominences.

Wound dressings Dry or moist ◦ Gauze ___________ ◦ Protects the wound from surface contamination ___________ ◦ Maintains a moist surface to support healing ______________ ◦ Uses negative pressure to support healing

Dry or moist ◦ Gauze Hydrocolloid ◦ Protects the wound from surface contamination Hydrogel ◦ Maintains a moist surface to support healing Wound V.A.C. ◦ Uses negative pressure to support healing

Skin Integrity and Wound - Heat and Cold Therapy

The health care provider determines the application time for heat. However, for cold, the maximum time is 20 to 30 minutes

Which national organization categorizes injuries as intentional or unintentional? The Joint Commission (TJC) Quality and Safety Education for Nurses (QSEN) Agency for Healthcare Research and Quality (AHRQ) National Center for Health Statistics (NCHS)

National Center for Health Statistics (NCHS)

Which teaching points will the nurse include when teaching a community group about injuries? Select all that apply. Unintentional injuries are unplanned incidents. Unintentional injuries typically result from deliberate acts of violence. Unintentional injuries do not account for many deaths within the United States. The risk factors for intentional injuries are better understood than those of unintentional injuries. Intentional injuries include events such as falls, drownings, and fire-associated injuries.

Unintentional injuries are unplanned incidents. The risk factors for intentional injuries are better understood than those of unintentional injuries.

Falls, drownings, and fire-associated injuries are considered _____________ injuries

unintentional

Which organization places a focus on patient safety when evaluating health care agencies for accreditation? The Joint Commission World Health Organization Centers for Disease Control and Prevention National Institutes of Health

The Joint Commission

The Joint Commission reevaluates National Patient Safety Goals every ___ months.

When teaching a community group about individual safety, which factors would the nurse include? Select all that apply. Workplace Physical age Developmental level Neighborhood environment Participation in school activities

Physical age Developmental level

Which factor is most likely the result of an impaired renal system? Alteration of senses Orthostatic hypotension Impaired excretion of medications Disruption of the body’s protective barrier

Impaired excretion of medications

Which safety risks would the nurse include when teaching the parents of an 18-month-old about safety precautions? Select all that apply. Choking on grapes Drowning in swimming pools Strangulation from blind cords Dehydration from sitting in a hot car Accidental ingestion of medication Head or neck injury related to trampoline use

Choking on grapes Drowning in swimming pools Strangulation from blind cords Dehydration from sitting in a hot car Accidental ingestion of medication

The nurse recognizes that poisoning symptoms can resemble symptoms of which other disorders? Select all that apply. Brain attack Seizure Alcohol intoxication Hypoglycemia Delirium Strep throat

Brain attack Seizure Alcohol intoxication Hypoglycemia Delirium

Which teaching would the nurse provide to a patient who asks how to best prepare fruits and vegetables to eat? Disinfect with an organic household cleaner. Rinse under running water. Use a small amount of dish detergent. Wash in solution made with 1 gallon of water and 1 teaspoon of bleach.

Rinse under running water.

Which types of footwear would the nurse recommend to a patient who plans to use a riding lawn mower regularly this summer? Select all that apply. Sneakers Velcro, nonslip shoes Shoes with sturdy laces Sandals, as the feet are away from blades Rubber boots

Velcro, nonslip shoes Shoes with sturdy laces

Nurses are professionally accountable for ___ Quality and Safety Education for Nurses competencies.

six

Which statement describes the main goal of the Quality and Safety Education for Nurses (QSEN) project? Prepare future nurses to advance quality and safety. Allocate resources for safety program implementation. Minimize the risk for harm to older adult patients by injury. Assist nurses to educate patients about safety concerns.

Prepare future nurses to advance quality and safety.

Educating patients about electrical cord safety is important in preventing:

fires as frayed electrical cords can start fires.

To assess the patient’s risk for exposure to biohazards in the home, which question would the nurse ask? Do you have air conditioning? What recreational activities do you engage in? Is there adequate outside lighting? Do you or does anyone in the home use hypodermic needles?

Do you or does anyone in the home use hypodermic needles?

Which member of the interprofessional team would the nurse consult to evaluate a patient for safe performance of activities of daily living (ADLs)? Social worker Physical therapist Occupational therapist Unlicensed assistive personnel

Occupational therapist

Which member of the interprofessional team would the nurse consult to evaluate a patient who is a fall risk? Health care provider Physical therapist Occupational therapist Unlicensed assistive personnel

Physical therapist

During an assessment, the nurse learns that a patient and child are living in a car. Which member of the interprofessional team would the nurse consult with to evaluate these individuals? Health care provider Social worker Physical therapist Occupational therapist

Social worker

A fire prevention plan must include changing batteries in smoke alarms (detectors) at least every ___ months

Many hospitals use the acronym RACE to describe emergency fire response. Which terms stand for the letters in RACE? Rescue, Advise, Comfort, Expedite Rescue, Alarm, Contain, Extinguish Restrain, Action, Continue, Emergency Resuscitate, Action, Control, Emergency

Rescue, Alarm, Contain, Extinguish

Which action would the nurse take first when discovering a fire in a patient’s room? Extinguish the fire. Contain the fire. Remove the patient from the room. Sound the alarm.

Remove the patient from the room.

The nurse is caring for a 72-year-old patient who is on bed rest after hip surgery for an injury sustained from a fall at home. The patient has a history of diabetes and ongoing dementia. Upon assessment, the nurse notes an intravenous (IV) infusion, a nasogastric tube, and a urinary drainage catheter. According to the Morse Fall Scale, what is the patient’s total score?

75 The patient is a high risk for falls: History of falling—25; Secondary diagnosis—15; Ambulatory aid—0; IV/heparin lock—20; Gait/transferring—0; Mental status—15 = 75 points.

A patient with paraplegia is being prepared for discharge from a spinal cord rehabilitation unit. Which question is most important for the nurse to ask when performing a home safety assessment? “Do you have a carbon monoxide detector?” “Do you have a plan to exit the home in case of an emergency?” “Where are your medications stored?” “Do you have a fire extinguisher?”

“Do you have a plan to exit the home in case of an emergency?”

The nurse is asking the patient a series of questions about the patient’s activities of daily living. The patient asks the nurse why that information is important. Which nursing response is appropriate? “The answers to these questions will help us determine if you need any assistance at home.” “This information will help your health care provider determine if you need to be placed in a skilled nursing facility.” “The questions are designed to get you to think about going home from the hospital.” “This is part of our regular patient assessment form that we must complete.”

“The answers to these questions will help us determine if you need any assistance at home.”

Which factor is a patient-related fall risk hazard? Wound drain Floor surfaces Intravenous access Incontinence

Incontinence

Which phrase describes medical asepsis? Absence of all infectious agents Procedure known as clean technique Requires use of sterile gloves Prevents microbial entry into body

Procedure known as clean technique Medical asepsis is also known as clean technique and includes hand hygiene and gloves to prevent the spread of microorganisms

Which statement is correct regarding hand hygiene in the health care setting? Soap and water effectively reduce microorganisms on visibly dirty hands. Infectious agents are killed by soap and water when washing hands. Washing hands with very hot water helps eliminate a greater number of bacteria. Non–alcohol-based hand sanitizers inhibit microorganism growth on hands.

Soap and water effectively reduce microorganisms on visibly dirty hands.

Which practices would be included by the nurse when teaching about standard precautions? Select all that apply. Hand hygiene Cough etiquette Patient cleanliness Safe injection practices Use of personal protective equipment (PPE)

Hand hygiene Cough etiquette Safe injection practices Use of personal protective equipment (PPE)

An effective alcohol-based hand scrub must contain at least __ percent alcohol.

The nurse removes PPE in the following order:

gloves, eyewear, gown, mask, shoe covers.

Which precaution would the nurse take when handling needles (sharps) to prevent an accidental needlestick? Recapping the needle after use Using a needleless system whenever possible Placing covered intravenous (IV) cannulas securely in the trash Flushing needles with water before disposing of them

Using a needleless system whenever possible

As a member of the infection control committee, which action would the nurse suggest to help control transmission of respiratory infections among staff during influenza season? Role model wearing gloves during patient care. Speak to peers about obtaining their immunizations. Teach hand hygiene to unlicensed assistive personnel. Post signs in bathrooms demonstrating cough etiquette.

Post signs in bathrooms demonstrating cough etiquette.

Which transmission-based precaution would the nurse take for a seriously ill patient being admitted for influenza? Avoid admitting through the reception area. Admit to an airborne infection isolation room. Obtain an N95 disposable respirator mask. Provide a mask for the patient if leaving the room.

Provide a mask for the patient if leaving the room.

Which source is best for the nurse to recommend for patients interested in information about the updated immunization schedule for adults? Their health care provider’s clinic or office The Centers for Disease Control and Prevention (CDC) immunization website Any health care provider at a local pharmacy The US government website

The Centers for Disease Control and Prevention (CDC) immunization website

Which home care intervention helps reduce the transmission of infections? Reporting infections as early as recognized Using disposable dishes and utensils Soaking clothing in bleach solution Isolating the infected individual from others

Reporting infections as early as recognized

Which diseases can the federal government order patients to be isolated and/or quarantined for? Select all that apply. Smallpox Human immunodeficiency virus (HIV)/Acquired immunodeficiency syndrome (AIDS) Measles Cholera Yellow fever Diphtheria

Smallpox Cholera Yellow fever Diphtheria

Which personal protective equipment (PPE) would the nurse don before observing a sterile procedure in the operating room? Mask Gown Hair cover Sterile gloves

Mask

Which intervention would a nurse anticipate specifically for a patient suspected of meningitis? Antibiotics Lumbar puncture Inputs and outputs Complete blood count

Lumbar puncture A lumbar puncture is a test specifically used to help with the diagnosis of meningitis

A lumbar puncture is a test specifically used to help with the diagnosis of ______________

meningitis

Which term describes the administration of a medication by a nurse? Dependent intervention Independent intervention Interdependent intervention Nurse-initiated intervention

Dependent intervention Dependent interventions require a written or an oral prescription from a health care provider and include the administration of a medication.

Which infection would require a nurse to don a fitted N95 respiratory mask? Tuberculosis Influenza Pneumonia Methicillin-resistant Staphylococcus aureus (MRSA)

Tuberculosis

Which infection would prompt the nurse to implement contact precautions? Hepatitis A Streptococcal pneumonia Influenza Chickenpox

Hepatitis A Hepatitis A is transmitted by direct contact from person to person. The nurse would implement contact precautions.

Which infection would require a patient to be admitted to the airborne infection isolation room? Pharyngeal diphtheria Meningococcal sepsis Staphylococcus aureus Varicella zoster

Varicella zoster This pathogen causes chickenpox. It is highly contagious and requires admitting the patient to an airborne infection isolation room.

Which type of action is the nurse taking to reduce the spread of infections by not going to work when sick? Personal Community Home Employee

Personal The nurse staying home is a personal action taken to help reduce the transmission of infection to other staff members and patients.

Which action can communities engage in to help reduce infections among their citizens? Encouraging and facilitating immunization programs Providing containers for used needle disposal to patients Assisting with health care environment modifications Educating patients about home infection control measures

Encouraging and facilitating immunization programs

Which action would the nurse recognize as a breach in surgical asepsis that contaminated the sterile field? Health care provider touched sterile field one-half inch from edge Health care provider reached over sterile field to pick up a towel Masked assistant talked over the sterile field Sterile packages opened facing away from body

Health care provider reached over sterile field to pick up a towel Reaching over the sterile field does contaminate the sterile field. The nurse would recognize this as a breach in surgical asepsis and call it to the attention of the health care provider.

Which procedure is necessary for equipment being used to enter a sterile body cavity? Sanitization Disinfection Sterilization Decontamination

Sterilization

A temperature below ________ indicates that an infection has resolved.

100.4°F (38°C)

Which aspect of the general history would the nurse focus on when caring for a patient with a hypothesis related to an infection? Recent travel Tobacco abuse Previous pregnancies History of hypertension

Recent travel

Which cue would support the nurse with a hypothesis of meningitis? Cough Hematuria Neck stiffness Abdominal pain

Neck stiffness Neck stiffness is a cue associated with meningitis. Additional cues that a nurse would anticipate include fever, headache, and confusion.

Which cue would indicate an infection to a nurse caring for a patient 2 days after a cesarean section? Productive cough Clean surgical wound Pain on ambulation Vaginal bleeding

Productive cough A productive cough would support the presence or raise the suspicion of a respiratory tract infection and require further evaluation. Postsurgical patients are at an increased risk for atelectasis and respiratory infections.

With whom would the nurse collaborate first when setting goals for a patient with a surgical wound at risk for infection? Health care team Caregiver Patient Therapist

Patient

Which goal is realistic for a nurse caring for a patient postoperatively? Patient’s wound will have no drainage after surgery. Patient will be fever free on the second postoperative day. Patient’s incision will heal without signs of infection by day 10. Patient will be pain free by the first postoperative day.

Patient’s incision will heal without signs of infection by day 10.

Which measurable goal would a nurse develop for a patient who is experiencing chest discomfort from a cough related to a respiratory infection? Coughing will improve within 12–24 hours of initiation of treatment. Patient complaints of chest discomfort from cough will decrease within 4 days. Productive cough will decrease within 48 hours of starting treatment. Patient will verbalize decreased chest discomfort related to cough within 2 days.

Patient will verbalize decreased chest discomfort related to cough within 2 days. This goal is measurable because it addresses the patient’s problem of chest discomfort related to cough, and patient verbalizations are measurable data.

Which cue would support the nurse with a hypothesis of a Urinary Tract Infection? Cough Hematuria Neck stiffness Abdominal pain

Hematuria Hematuria is a cue associated with a urinary tract infection. Additional cues that a nurse would anticipate include fever, polyuria, dysuria, and foul-smelling, cloudy urine.

Which patient behavior supports the nurse’s hypothesis of a knowledge deficit? Refusal to eat yogurt served on lunch tray Inability to perform incisional care Explanation from patient about correct diet Untouched informational booklets at bedside

Inability to perform incisional care This behavior supports the nurse’s hypothesis of a knowledge deficit. The patient either lacks the knowledge about how to perform the procedure or needs instruction and practice performing the procedure.

Which nursing hypothesis would the nurse add to the care plan after noting an open pressure injury on the patient’s coccyx during assessment? Lack of Knowledge Impaired Skin Integrity Impaired Nutritional Status Acute Pain

mpaired Skin Integrity Impaired Skin Integrity is the nursing hypothesis the nurse should place on the patient’s care plan. It addresses the patient’s open pressure injury.

Mnemonic for blood cells frequency

Never Let Monkeys Eat Bananas

Which white blood cells are responsible for the signs and symptoms of inflammation? Neutrophils Monocytes Eosinophils Basophils

Basophils Basophils release vasoactive mediators, such as histamine, which are responsible for the signs and symptoms of inflammation: redness, heat, swelling, and pain.

Which patient finding is indicative of a localized infection? Tachycardia Fatigue Abscess Chills

Abscess An abscess is a patient finding indicative of a localized infection because it is limited to a specific area, such as a boil or dental pocket.

Erythrocyte sedimentation rate (ESR) The ESR is elevated during active:

inflammation. Because infection causes inflammation, it is also elevated during infection.

Which living substance functions as an antigen? Toxins Chemicals Drugs Proteins

Proteins

Which type of immunity serves as the body’s first line of defense by providing immediate protection against foreign antigens? Active immunity Passive immunity Adaptive immunity Innate immunity

Innate immunity Innate immunity serves as the body’s first line of defense and provides immediate protection against foreign antigens.

Which term describes a microorganism that causes serious disease? Pathogen Antigen Virulent Invasive

Pathogen

Which mechanism explains how normal flora protects against infection? Inhibits microorganisms from colonizing Prevents pathogens from entering circulation Destroys infectious agents on body surfaces Neutralizes and eliminates foreign antigens

Inhibits microorganisms from colonizing

Which body system has proteins with antimicrobial properties and promotes phagocytosis? Respiratory system Gastrointestinal system Integumentary system Musculoskeletal system

Respiratory system

Which immune response is mediated by circulating antibodies that coat antigens and target them for destruction? Humoral immunity Innate immunity Adaptive immunity Cellular immunity

Humoral immunity Humoral immunity is also known as antibody-mediated immunity. It uses specialized cells to produce antibodies that respond to foreign antigens or pathogens.

___________ immunity is also known as antibody-mediated immunity. It uses specialized cells to produce antibodies that respond to foreign antigens or pathogens.

Humoral

Which cells are responsible for the production of antibodies? T-helper cells Phagocytes B lymphocytes Macrophages

B lymphocytes

Which adaptive immune system cells release interleukins to stimulate antibody production by B cells? Complements Macrophages T-helper cells Basophils

T-helper cells

Which function would a nurse recognize as an adaptive immune response? Initiating the inflammatory response Producing chemical mediators Phagocytizing foreign substances Triggering lymphocyte production

Triggering lymphocyte production

Which type of immunity initially protects a person from infection after receiving a skin laceration? Adaptive immunity Innate immunity Humoral immunity Passive immunity

Innate immunity

Which component is part of innate immunity and participates in the inflammatory response? Leukocytes Helper cells Cytotoxic T cells Immunoglobulins

Leukocytes Leukocytes, or white blood cells (WBCs), are important components participating in inflammation. They provide defense through phagocytosis, enzymes, and cleaning up debris after the inflammatory response.

A microorganism is considered to be resistant if it cannot be stopped by the use of __ or more antibiotics.

Which phenomenon causes microbial resistance? Microorganisms adapting to their environment Infectious agents developing greater virulence Pathogens changing replication patterns Bacteria developing protective outer coats

Microorganisms adapting to their environment

Which factor that contributes to antimicrobial resistance is considered an infection control issue? Congested health settings Patient nonadherence Population of urban centers Lack of patient education

Congested health settings An infection control issue is that of overcrowding of hospitals and clinics where both infected and well persons are exposed to infected persons and thus pathogens.

health care–associated infection (HAI) are infections acquired by patients while___________________________________within the health care setting.

receiving treatment for other conditions

Which pathogen cannot be treated with antibiotics because it has a protective envelope? Bacterium Virus Fungus Parasite

Virus

Which precaution would be implemented for a patient admitted for suspected West Nile virus? Contact Droplet Airborne Standard

Standard Standard precautions would be implemented for this patient because West Nile virus is transmitted by a vector, specifically mosquitos. There are no other precautions required for vector-transmitted pathogens.

Which factor is most likely to contribute to the development of a health care–associated respiratory infection in an ambulatory diabetic patient receiving an intravenous antibiotic? Excessive activity Decreased oxygenation Current comorbidity Incorrect antibiotic

Current comorbidity Diabetes mellitus places the patient at increased risk for development of a health care–associated infection.

Which rationale explains why antibiotic use in animals contributes to human antimicrobial resistance? Creates a reservoir of potentially resistant bacteria Allows for greater exposure to multiple pathogens Promotes new vectors as sources of transmission Lack of hygiene and sanitation in animal holding areas

Creates a reservoir of potentially resistant bacteria Use of antibiotics to treat livestock and fish as a preventive measure is overuse of antibiotics. This contributes to antimicrobial resistance by creating a reservoir of potentially resistant bacteria.

Which statement is phrased as a desired outcome for a pediatric patient being treated for head lice? Child’s hair will be cleansed with medicated shampoo daily. Bed linens will be washed in hot, soapy water once weekly. Child refrains from sharing personal items with school classmates. Mother will find no evidence of lice in the child’s hair within 1 week.

Child refrains from sharing personal items with school classmates. This is a desired outcome, meaning the goal of teaching the child not to share personal items is being met. The child is refraining from sharing personal items at school.

Which action by the nurse demonstrates a collaborative approach to improving a patient’s ability to perform self-hygiene and personal care? Assigning the unlicensed assistive personnel (UAP) to comb the patient’s hair Partnering with the occupational therapist Asking the family to care for the patient’s needs Reporting on patient needs to the oncoming nurse

Partnering with the occupational therapist Partnering with the occupational therapist is collaboration because both health care team members work together to plan interventions for the common goal of improving the patient’s ability to perform self-hygiene and personal care.

Which action would the nurse take when a patient requests a same gender caregiver for hygiene and personal care because of cultural preferences? Request the family to provide care. Collaborate with social services. Accommodate the patient’s wishes. Assess the patient’s hygiene needs.

Accommodate the patient’s wishes.

Which example shows a correctly stated hygiene and personal care long-term goal? Patient will shower independently by the end of 1 month. Self-care deficit will be resolved within 3 to 6 days. Patient will use toothbrush to perform oral hygiene without assistance. Within 24 hours, patient will bathe with the help of one person.

Patient will shower independently by the end of 1 month.

A patient exhibits matted hair and caked mud and debris under fingernails and toenails. Which nursing hypothesis would the nurse select? Activity Intolerance Pressure Ulcer/Injury Self-Care Deficit Impaired Oral Mucous Membrane

Self-Care Deficit

The nurse would give extra attention to assessing for infections on and around the nails in a patient with which condition? Halitosis Pediculosis Diabetes Dandruff

Diabetes Patients with diabetes are prone to infections on and around the nails because of decreased circulation and a weakened immune system.

Which skin conditions might be present if a patient is having an allergic reaction to something he or she touched?

Contact dermatitis Rash

Which piece of clothing would the nurse remove when looking for excoriations? Socks Pants Headband Adult diaper

Adult diaper A patient wearing an adult diaper indicates the skin is exposed to stool and urine, which is a major risk factor for excoriation and skin breakdown.

When reviewing a patient’s chart, the nurse notes documentation of a pressure injury. Which finding would the nurse expect upon assessment? Open wound over the sacrum Red, scaly lesion on buttocks Purplish discoloration under the cheek An infected surgical wound

Open wound over the sacrum

Which type of injury results in a puncture wound? Paper cut Dog bite Popped blister Black eye

Dog bite

A nurse is performing an initial assessment on a recently admitted patient. Which finding warrants an immediate call to the health care provider? Presence of pediculosis Halitosis related to poor oral hygiene Oily, matted, and tangled hair Warm, moist, and intact skin

Presence of pediculosis Pediculosis, or a lice infestation of the body hair, warrants immediate treatment and a phone call to the health care provider for prescriptions. This is not a normal finding and requires treatment before it spreads to other patients and health care staff.

Which patient situation indicates that a sink bath is appropriate? Needs support while standing Requires assistance to move from bed to sink Can perform part of the sink bath independently Provides own bathing supplies

Can perform part of the sink bath independently

Which action by a female patient lets the nurse know the patient has understood perineal care teaching? The patient washes her perineum with a circular motion beginning at the urinary meatus. The patient washes her perineum from front to back using a clean washcloth. The patient washes her perineum from back to front with a clean washcloth. The patient washes her perineum lightly to prevent tissue damage.

The patient washes her perineum from front to back using a clean washcloth.

For which reason is it contraindicated for a patient with peripheral neuropathy to soak the feet? Can cause increased circulation Can cause tissue drying and increase risk for infection Is painful for the patient May make patient unable to walk

Can cause tissue drying and increase risk for infection

Which type of massage is best for patients with deep muscle tension? Petrissage Effleurage Tapotement Percussion

Petrissage

Which type of bath is appropriate for an older adult patient who ambulates with a cane and has a history of unsteadiness? Sink bath Chair shower Partial bed bath Complete bed bath

Chair shower A chair shower is the best option for a patient with a history of ambulatory unsteadiness.

Which benefit does a sitz bath provide for a new mother? Regulates skin pH Eliminates pediculosis Decreases swelling Decreases halitosis

Decreases swelling A sitz bath is used after childbirth to decrease swelling, inflammation, and pain.

Which action must the nurse perform before a patient receives a shower? Ensure the patient would like to take a shower. Make sure a shower chair is available. Determine if the patient will take a stand-up shower or use a shower chair. Check the health care provider’s prescription to determine if showering is safe.

Check the health care provider’s prescription to determine if showering is safe.

A nurse is instructing a newly blind patient how to clean the eyes. Which instruction would the nurse provide? Use plain water and wipe from the outer canthus to the inner canthus. Use soapy water and wipe from the inner canthus to the outer canthus. Use sterile water and wipe from the outer canthus to the inner canthus. Use plain water and wipe from the inner canthus to the outer canthus.

Use plain water and wipe from the inner canthus to the outer canthus. Eyes should be washed from the inner canthus to the outer canthus using plain water.

Which action is taken for a patient receiving oxygen with a nasal cannula to prevent nasal passages from drying? Humidifying the oxygen Warming the oxygen Cooling the oxygen Lowering the oxygen

Humidifying the oxygen Humidifying the oxygen can help relieve dryness in the nasal passages when oxygen is delivered via nasal cannula.

Which function is associated with sebaceous glands? Keep the hair and skin soft. Generate new hair. Keep particles from entering the body. Cool the body.

Keep the hair and skin soft. Sebaceous glands are an accessory organ of the skin that secretes sebum, which keeps the hair and skin soft.

Patients being treated with _________________ are very susceptible to oral infections, dryness, and tissue damage.

chemotherapy

Proper perineal care is extremely important for females as they are prone to which condition? Fungal infections of the skin folds Acne Bruises Urinary tract infections

Urinary tract infections

Which statement by the nurse best expresses the proper approach to perineal care to a patient of the opposite sex? “If you don’t want me to do it, you can do it yourself!” “I’ll be fast and efficient, as if I was never even there.” “I’ll get the health care provider to do it, but I don’t know how long that will take.” “If at any time you feel uncomfortable, please let me know.”

“If at any time you feel uncomfortable, please let me know.”

The nurse is tasked with catheter insertion on a patient of Middle Eastern descent who is of the opposite sex. Which approach would the nurse take when initiating the procedure? Avoid eye contact throughout the entire procedure. Knock first, explain the procedure, and ask for the patient’s comfort level. Ask for help from the health care provider to perform the procedure. Ask for help from family to convince the patient to allow the procedure

Knock first, explain the procedure, and ask for the patient’s comfort level.

A nurse is caring for an older adult woman with advanced dementia who is incapable of self-care. However, the patient insists on brushing her own teeth at bedtime. Which action would the nurse take? Allow her to brush her own teeth independently. Allow her family to brush her teeth for her. Get another nurse to brush the patient’s teeth. Allow her to brush her teeth with supervision.

Allow her to brush her teeth with supervision.

Which component of the integumentary system is the first line of defense against microorganisms? Nails Sweat glands Skin Hair

Skin

Which description regarding the subcutaneous skin layer is correct? Produces melanin Can be called the dermis Provides a cushioning effect Is the outermost layer of the skin

Provides a cushioning effect The subcutaneous skin layer, which consists of adipose tissue, provides a cushioning effect for internal organs.

Which function will be compromised if the dermis is injured? Immune response Temperature regulation Blood supply to the skin Protection for internal organs

Blood supply to the skin Supplying blood to the skin is a function of the dermis; thus, if this area is injured, the blood supply will be negatively affected.

Which response is a result of poor perfusion to the skin? Development of maceration Excessive collagen formation Reduced production of fibroblasts Increased migration of cells that help skin regenerate

Reduced production of fibroblasts

Which substance provides the skin with color? Keratin Melanin Collagen Elastin

Melanin

Which patient situation is an example of friction? A patient sitting up in bed A patient who has diabetes A patient lying in the same position for 4 hours A patient’s leg rubbing against the side rail of a bed

A patient’s leg rubbing against the side rail of a bed

Which statement about ultraviolet light is accurate? Ultraviolet light A (UVA) penetrates the dermis. Both UVA and UVB affect the subcutaneous layer. Ultraviolet light B (UVB) penetrates skin more deeply. Both UVA and UVB affect hemoglobin’s ability to carry oxygen.

Ultraviolet light A (UVA) penetrates the dermis.

Which change is associated with aging of the skin? Thinned dermis, resulting in increased elastin production Decreased melanocytes, resulting in loss of hair color and decreased risk for skin cancer Increased production of Langerhans cells, resulting in decreased resistance to infections Reduced insulation and cushioning, resulting in an increased risk for skin trauma and heat loss

Reduced insulation and cushioning, resulting in an increased risk for skin trauma and heat loss Reduced insulation and cushioning increase the risk for skin trauma and heat loss. Without cushioning over bony prominences, older adults are at risk for injuries to the skin.

Which wound is classified as a closed wound? Bruise Abrasion Surgical incision Puncture wound

Bruise

Which information would the nurse share with a patient about wound healing by tertiary intention? The wound will heal quickly with minimal scarring. The wound will have approximated edges in several days. The wound will be immediately sutured for about 7 to 10 days. The wound will be closed later when the infection risk is reduced.

The wound will be closed later when the infection risk is reduced.

Which term describes the last phase of wound healing? Maturation Coagulation Proliferative Inflammatory

Maturation Maturation, or remodeling, is the last phase of wound healing. During maturation, collagen continues to be deposited, and scars are formed and strengthened.

Which primary objective does the proliferative phase of wound healing achieve? Clotting of blood Producing granulation tissue Scarring of the wound Cleaning of the wound by macrophages

Producing granulation tissue The proliferative phase begins the process of producing granulation tissue that is red and beefy in appearance.

Which complication allows visceral organs to be exposed through an incision? Fistula Dehiscence Evisceration Hemostasis

Evisceration Evisceration is the total separation of tissue layers, allowing protrusion of visceral organs through an incision.

Which definition of a fistula is correct? Muscular layer of tissue that forms after wound healing Creation of new blood vessels during wound healing Nervous system pathway between two areas of the body Abnormal connection between two internal organs

Abnormal connection between two internal organs A fistula is an abnormal channel between two internal organs or between an internal organ and the skin.

Which statement regarding the skin is accurate? It has a minimal role in body temperature. It is closely linked to personal identity. It has no role in cultural perception. It alerts a person to danger through electrolyte balance.

It is closely linked to personal identity.

Which cells join the epidermis and dermis and are arranged in a single layer? Basal cells Melanocytes Fibroblasts Keratinocytes

Basal cells Basal cells compose a single layer of active cells that join the epidermis and dermis.

Which response is likely when a patient who has a full-thickness wound receives a steroid? Healing time will slow. Infection will be eliminated. Malnutrition will result. Shear will be decreased.

Healing time will slow. Steroids, which are antiinflammatories, interrupt the inflammatory process, making patients prone to infections and slow healing.

Which characteristic accurately describes the dermis? Consists of dead skin cells Is an area for sebaceous glands Has the same thickness regardless of location Contains adipose tissue

Is an area for sebaceous glands Sebaceous (oil) glands are located in the dermis.

Which strategy would the nurse use to classify a burn? According to drainage According to source of burn According to the skin layer damaged According to contamination factor

According to the skin layer damaged

Which phase of wound healing is characterized by a patient who reports that the bumpy and granular injured site “bleeds easily”? Maturation Unstageable Proliferative Inflammatory

Proliferative The proliferative phase is the phase of healing and repair in which new tissue bleeds easily and has a granular and bumpy texture.

Agency for Healthcare Research and Quality (AHRQ) AHRQ provides evidence-based practice for _________ care guidelines, and the nurse would use its guidelines.

wound

Which food would the nurse suggest the patient consume to increase zinc in the diet for wound healing? Apricots Kiwi Fish Molasses

Fish

Which patient scenario would prompt the nurse to question a prescription for cold therapy? Correct Answer Exactly! Has a strong pulse Has edema present Has an absence of cyanosis Has 16 respirations per minute

Has edema present

Which piece of equipment would the nurse likely obtain for a patient who has a prescription for therapy that is primarily heat only? Pack Sitz bath Moist soak Moist compress

Sitz bath

Which cue alerts the nurse that a patient receiving cold therapy is improving? Edema Psychological relaxation Increased blood flow to area Relief from muscle spasms

Relief from muscle spasms

Which solution would the nurse obtain to clean a patient’s arm wound? Dakin’s solution Povidone-iodine Hydrogen peroxide Normal saline

Normal saline

Which cue is relevant for a patient who has a wound? Living in a northern state Having a high creatinine level Being male Having a low prealbumin level

Having a low prealbumin level A low prealbumin level is a relevant cue regarding a wound because it indicates that protein levels are low and could affect wound healing.

Which type of fluid would the nurse likely observe if the patient was hemorrhaging? Serous Serosanguineous Sanguineous Purulent

Sanguineous

____________ fluid is bright red, and it indicates bleeding that is observed in hemorrhaging.

Sanguineous

____________ the area of induration is an effective way to assess if an incision is healing or becoming infected; an infected incision will have induration (hardness) around the incision.

Palpating

Safety restraints - they are used:

as the last resort. Other options: provide distraction, sitter/family

Stage 1 pressure ulcer

intact skin with non-blanchable redness

Stage 2 pressure ulcer

Partial-thickness skin loss involving epidermis, dermis, or both

Stage 3 pressure ulcer

Full-thickness tissue loss with visible fat

Stage 4 pressure ulcer

Full-thickness tissue loss with exposed bone, muscle, or tendon

Wound healing Primary - staples, sutures Secondary - open wounds / wet to dry dressing changes Tertiary - delayed primary closure (big hole; leave it open; heals over time with antibiotics/surgery..). Rare.

Primary - staples, sutures Secondary - open wounds / wet to dry dressing changes Tertiary - delayed primary closure (big hole; leave it open; heals over time with antibiotics/surgery..). Rare.

Tertiary intention of wound healing:

delayed primary closure

◦ _________ Scale - Physical and mental condition, activity, mobility, and continence

Norton

◦ _________ Scale - Sensory perception, moisture, activity, mobility, nutrition, and friction and shear

Braden

RACE stands for

Rescue, Alarm, Contain, Extinguish

Nursing process steps

ADPIE Assessment Diagnosis Planning Implementation Evaluation

Reactive hyperemia occurs when tissue is relieved of pressure. It is considered abnormal when the redness lasts longer than _______ and the surrounding tissue does not blanch.

1 hour

Palpable changes in the consistency of the tissue underlying a bony prominence, often described as "_________," is an indication that pressure damage has occurred

spongy

Thirty-degree lateral inclined position. This position best reduces pressure on bony prominences where ___ frequently develop. Pillows and foam wedges may be used for support and protection in this position.

Purulent refers to something that contains or produces ______ . [an indication that an infection is likely]

pus

To reduce the effects of moisture on the client's skin, which intervention should be implemented? Apply a moisture-repellent ointment to intact skin areas. Rinse ulcerated areas with an alcohol-based irrigating solution. Position a plastic-lined pad under the buttocks. Apply moist heat to the area following exposure to feces.

Apply a moisture-repellent ointment to intact skin areas.

The client infected with methicillin-resistant Staphylococcus aureus (MRSA) should be cared for using _________ precautions when there is potential for wound drainage and debris to splatter during care.

contact The mode of transmission of MRSA includes direct contact, as well as contact with infected surfaces.

What is the purpose of wet to dry dressing? Mechanically debride the tissue. Facilitate tissue healing. Decrease risk of infection. Preserve granulation tissue.

Mechanically debride the tissue.

Incorrectly labeled medications are the responsibility of the :

pharmacist

_____________ must be deposited in the bone to increase bone density.

Calcium

The _________ Scale assesses many risk factors that may contribute to pressure sores.

Braden

How should the nurse assess for orthostatic hypotension? Measure the client's pulse while the client is in the sitting and standing positions. Measure the client's blood pressure while the client is in the lying and standing positions. Take the client's pulse and blood pressure when the client is in the lying and sitting positions. Take the client's blood pressure and pulse while the client is in the lying, sitting, and standing positions.

Take the client's blood pressure and pulse while the client is in the lying, sitting, and standing positions. Orthostaic hypotension can occur when the client has been lying or sitting for a prolonged period and quickly rises to an erect position. The systolic blood pressure must drop a minimum of 20 points to be considered orthostatic hypotension.

Chain of infection

Infectious agent Reservoir Portal of exit Mode of transmission Portal of entry Host

ABC's

Priorities Airway Breathing Circulation

Physical hazards include

lighting bathroom hazards reckless behaviors rugs fire cords bed height transmission of pathogens

Individual risk factors impacting pt safety:

lifestyle impaired mobility sensory / communication impairment lack of safety awareness improper infection prevention of caregivers

The nurse is caring for an older-adult patient admitted with nausea, vomiting, and diarrhea due to food poisoning. The nurse completes the health history. Which priority concern will require collaboration with social services to address the patient's health care needs? A. The electricity was turned off 3 days ago. B. The water comes from the county water supply. C. A son and family recently moved into the home. D. This home is not furnished with a microwave oven.

A. The electricity was turned off 3 days ago.

National Patient Safety Goals

Improve accuracy of patient ID, effectiveness of communication among caregivers (EHR [electronic health record], SBAR), safety of using meds Medication reconciliation Fall reduction Reduction of healthcare associated infections Encourage patient involvement Reduce risk for fires

The nurse discovers a patient on the floor. The patient states that he fell out of bed. The nurse assesses the patient and places the patient back in bed. Which action should the nurse take next? A. Do nothing, no harm has occurred. B. Notify the health care provider. C. Complete an incident report. D. Assess the patient.

B. Notify the health care provider. Report immediately to physician or health care provider if the patient sustains a fall or an injury. The nurse must provide safe care, and doing nothing is not safe care. The scenario indicates the nurse has already assessed the patient. After the patient has stabilized, completing an incident report would be the last step in the process.

A home health nurse is assessing the home for fire safety. Which information from the family will cause the nurse to intervene? (Select all that apply.) A. Smoking in bed helps me relax and fall asleep. B. We never leave candles burning when we are gone. C. We use the same space heater my grandparents used. D. We use the RACE method when using the fire extinguisher. E. There is a fire extinguisher in the kitchen and garage workshop.

A. Smoking in bed helps me relax and fall asleep. C. We use the same space heater my grandparents used. D. We use the RACE method when using the fire extinguisher.

Signs of local inflammatory process:

heat redness pain tenderness swelling edema loss of function

Positive VS negative pressure

Positive pressure- HIGH pressure inside - air leaves room - protects PT Negative pressure- LOW pressure inside - air does not leave room - protects outsiders

What precautions are used for CMV, HIV, Hepatitis B/C, Aspergillosis

Standard

What will the nurse wear by pts who have TB, SARS, or avian influenza?

N-95 mask

What precautions are used for pertussis, influenza A/B, MRSA, Meningitis, RSV, Mumps, Rubella?

Droplet

What precautions are used for MRSA, VRE, Adenovirus, diarrhea, C. Diff., Rotavirus, E. Coli, Enterovirus, Salmonella, Hep. A., Shingles, Herpes Simplex, RSV, Lice, Scabies, Chicken Pox?

Contact

Clean VS Sterile technique

Clean- reduce the number of pathogens; administration of meds, tube feeding, daily hygiene Sterile technique- eliminates all pathogens; dressing changes, catheterizations, surgical procedures

Factor's influencing personal hygiene

obesity body image homelessness socioeconomics culture preferences beliefs/ motivation

A nurse is preparing to provide hygiene care. Which principle should the nurse consider when planning hygiene care? a. Hygiene care is always routine and expected. b. No two individuals perform hygiene in the same manner. c. It is important to standardize a patient's hygienic practices. d. During hygiene care do not take the time to learn about patient needs.

b. No two individuals perform hygiene in the same manner.

The nurse is caring for a patient who refuses to bathe in the morning. When asked why, the patient says "I always bathe in the evening." Which action by the nurse is best? a. Defer the bath until evening and pass on the information to the next shift. b. Tell the patient that daily morning baths are the "normal" routine. c. Explain the importance of maintaining morning hygiene practices. d. Cancel hygiene for the day and attempt again in the morning.

a. Defer the bath until evening and pass on the information to the next shift.

6 rights of med administration

Patient Medication Dose Route Time Documentation

Wound Healing (Primary, Secondary, tertiary intentions)

Primary- surgery; neatly approximated; surgical incision; fine scar Secondary- wounds from trauma/injury/infection, irregular margins; larger scar Tertiary- delayed suturing; deeper scar

Wound repair- 4 step process

Hemostasis Inflammatory Proliferative Maturation

___________ - partial or total separation of wound layers

Dehiscence

__________ - abnormal passage from an internal organ to to the surface of the body or between 2 internal organs

Fistula

__________ - an abnormal proliferation of scar tissue

Keloid

___________ scar - similar to keloid but growth confined w/in boundaries of original skin defect & may respond to treatment; may look red

hypertrophic

_____________ - when a large area of skin is damaged and lost, resulting in a scar that pulls the edges of the skin together, causing a tight area of skin

Contracture

_________ - scarring that forms between unconnected, internal organs

Adhesion

A wound vac uses ________________ to support healing

negative pressure sucks out drainage

Jackson-pratt removes wound drainage from

tube and reservoir

A nurse is assessing a patient's skin. Which patient is most at risk for impaired skin integrity? A. an afebrile patient B. A patient who is diaphoretic C. A patient with strong pedal pulses D. A patient with adequate skin turgor

B. A patient who is diaphoretic

The nurse is caring for a patient who is immobile. The nurse frequently checks the patient for impaired skin integrity. What is the rationale for the nurse's action? A Inadequate blood flow leads to decreased tissue ischemia. B Patients with limited caloric intake develop thicker skin. C Pressure reduces circulation to affected tissue. D Verbalization of skin care needs is decreased.

C Pressure reduces circulation to affected tissue.

The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a Stage III pressure ulcer. The wound seems to be healing, and healthy tissue is observed. How should the nurse document this ulcer in the patient's medical record?

Healing Stage III pressure ulcer

The nurse is caring for a patient with a stage IV pressure ulcer. The nurse recalls that a pressure ulcer takes time to heal and is an example of a. Primary intention. b. Partial-thickness wound repair. c. Full-thickness wound repair. d. Tertiary intention.

c. Full-thickness wound repair.

The nurse is caring for a patient who is experiencing a full-thickness repair. The nurse would expect to see which of the following in this type of repair? Eschar Slough Granulation Purulent drainage

Granulation

A nurse is assessing a patient's wound. Which nursing observation will indicate the wound healed by secondary intention? a. Minimal loss of tissue function b. Permanent dark redness at site c. Minimal scar tissue d. Scarring that may be severe

d. Scarring that may be A wound healing by secondary intention takes longer than one healing by primary intention. The wound is left open until it becomes filled with scar tissue. If the scarring is severe, permanent loss of function often occurs. Wounds that heal by primary intention heal quickly with minimal scarring. Scar tissue contains few pigmented cells and has a lighter color than normal skin.

The nurse is caring for a patient with a healing Stage III pressure ulcer. The wound is clean and granulating. Which health care provider's order will the nurse question? a. Use a low-air-loss therapy unit. b. Irrigate with Hydrogen peroxide c. Apply a hydrogel dressing. d. Consult a dietitian.

b. Irrigate with Hydrogen peroxide Clean pressure ulcers with noncytotoxic cleansers such as normal saline, which will not kill fibroblasts and healing tissue. Cytotoxic cleansers such as Dakin's solution, acetic acid, povidone-iodine, and hydrogen peroxide can hinder the healing process and should not be utilized on clean granulating wounds.

Wounds should only be irrigated with

saline no chemicals

The nurse is caring for a surgical patient. Which intervention is most important for the nurse to complete to decrease the risk of pressure ulcers and encourage the patient's willingness and ability to increase mobility? a. Explain the risks of immobility to the patient. b. Turn the patient every 3 hours while in bed. c. Encourage the patient to sit up in the chair. d. Provide analgesic medication as ordered

d. Provide analgesic medication as ordered [pain meds could help their pain which would allow them to move more]

The nurse has collected the following assessment data: right heel with reddened area that does not blanch. What nursing diagnosis would the nurse assign? a. Ineffective tissue perfusion b. Risk for infection c. Imbalanced nutrition: less than body requirements d. Acute pain

a. Ineffective tissue perfusion

The nurse is caring for a patient with potential skin breakdown. Which components will the nurse include in the skin assessment? A. Mobility B. Hyperemia C. Induration D. Blanching E. Temperature of skin F. Nutritional Status

B. Hyperemia C. Induration D. Blanching E. Temperature of skin