week 3 ati --ch 5 & hw

Question 1

vehicle transmission

Answer 1

transmission from contaminated items to multiple persons
*E.coli on produce

Question 2

Inflammatory Response Stages

Answer 2

1. Bacteria invade an open wound
2. Histamine, Kinins, & prostaglandins arrive @ site
3. Plasma from blood enters the site
   4.Phagocytosis occurs
4. Pus develops

Question 3

Stages of Infection

Answer 3

1. Incubation Stage–no symptoms
2. Prodromal Stage –nonspecific symptoms
   3.Acute Illness –specific symptoms
3. Period of Decline
4. Period of Convalescence–feels better

Question 4

wash hands for how long

Answer 4

15-30 seconds

Question 5

Preparing a Sterile Field

Answer 5

*flat surface 12-18in away from walls
*items placed in middle (1in border)
*peel flaps away from body–farthest package first
*peel sides 1 at a time

Question 6

contact precautions

Answer 6

gown & gloves
client in private room

Question 7

droplet precautions

Answer 7

surgical mask
private room

Question 8

airborne precautions

Answer 8

respirator mask
private room w door closed
client must wear mask
AIIR room

Question 9

4 major HAI’s

Answer 9

1. central line-associated bloodstream infection
2. Catheter associated UTI
3. surgical site infection
4. ventilator assisted pneumonia’s

Question 10

Infection Control bundles

Answer 10

guideline for practice to help prevent HAI’s

Question 11

PPE application order

Answer 11

1. gown
2. mask
   3.goggles
3. gloves

Question 12

PPE Removal Order

Answer 12

1. gloves
2. goggles/shield
3. gown
4. mask

Question 13

Obtaining a Throat Culture

Answer 13

*avoid if epiglottis is inflamed
*resuscitation equipment nearby
*wait 1 hr if client ate
1. check for indications of infection
2. gather info
3. client sit upright
4. have client hyperextend neck w/ tongue out saying ‘ah’
5.apply pressure to anterior 3rd of tongue w tongue blade while visualizing oropharynx w penlight
6. remove tongue blade
7. Use sterile swab & insert to posterior oropharynx only
8. gently swab oropharynx, tonsils & red areas/exudate
9 assess pain

Question 14

when a client is taking anticoagulants a nurse must continually monitor..

Answer 14

weight
renal
hepatic
dosage frequency
amount prescribed
drug interaction

Question 15

suicidal ideation is assessed in all clients begininng

Answer 15

at age 12

Question 16

R.A.C.E.

Answer 16

R-rescue
A-alarm
C-contain
E-extinguish

Question 17

Class A Fire Extinguisher

Answer 17

water-based–paper, plastic, wood, cloth, & rubber

Question 18

Class B fire extinguisher

Answer 18

CO2—oils, gas, grease, & paint

Question 19

class c fire extinguisher

Answer 19

dry chemicals–electrical fires

Question 20

class D fire extinguisher

Answer 20

metals – magnesium, potassium, sodium, & titanium

Question 21

Class K fire extinguisher

Answer 21

kitchen–oils & fats

Question 22

Alpha

Answer 22

least risky radiation exposure—no penetration

Question 23

Beta

Answer 23

middle risk radiation–special clothes required

Question 24

Gamma

Answer 24

highest radiation risk–penetrates skin & lead protection

Question 25

elopement

Answer 25

client leaves or wanders away from a health care facility

Question 26

a nurse is preparing info for a change-of-shift report. Which of the following should the nurse include in the report?

1. Input & output for the shift
2. Blood pressure from the previous day
3. Bone scan scheduled for today
4. Medication routine from the medication administration record

Answer 26

Bone scan scheduled for today

Question 27

A nurse manager is discussing HiPPA…what should she include?

1. A single electronic records password is provided for nurses on the same unit
2. Family members should provide a code prior to receiving client health info

3.Communication of client info can occur at the nurses station

4. a client can request a copy of their medical record
5. a nurse can photocopy a clients medical record for transfer to another facility

Answer 27

2. Family members should provide a code prior to receiving client health info
   3.Communication of client info can occur at the nurses station
3. a client can request a copy of their medical record
4. a nurse can photocopy a clients medical record for transfer to another facility

Question 28

Which of the following legal guidelines should be followed when documenting in a client’s record? (select all that apply)

1. cover errors with correction fluid & write in the correct information
2. Put the date & time on all entries
3. Document objective data, leaving out opinions
4. Use as many abbreviations as possible
5. Wait until the end of the shift to document

Answer 28

2. Put the date & time on all entries
3. Document objective data, leaving out opinions

Question 29

A nurse is discussing occurrences that require incident reports. Which of the following should the nurse include in the teaching? (Select all that apply)
1. Medication error
2. Needlesticks
3.Conflict w/ provider & nursing staff
4. Omission of prescription
5. Missed specimen collection of a prescribed lab test

Answer 29

1. Medication error
2. Needlesticks
3. Omission of prescription

Question 30

A nurse is receiving a provider’s prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? (select all that apply).

1. Repeat the details of the prescription back to the provider
2. Have another nurse listen to the telephone prescription
3. Obtain the provider’s signature on the prescription within 24hrs
4. Decline the verbal prescription because it is not an emergency
5. Tell the charge nurse that the provider has prescribed morphine by telephone

Answer 30

1. Repeat the details of the prescription back to the provider
2. Have another nurse listen to the telephone prescription
3. Obtain the provider’s signature on the prescription within 24hrs

Question 31

Subjective Data
vs
Objective Data

Answer 31

Sub — what the client says direct quotes

Obj—what the nurse sees, feels, hears, & smells

Question 32

Begin all data entries with

Answer 32

date & time

Question 33

flow charts

Answer 33

show TRENDS in levels
** vital signs, blood glucose levels, & pain levels

Question 34

Types of Problem Oriented Medical Records (3)

Answer 34

1. S.O.A.P. = Subjective data, Objective data, Assessment, Planning
2. P.I.E. = Problem, Intervention, & Evaluation
3. D.A.R. = Data, Action, & Response

Question 35

clinical pathways

Answer 35

standardized method of health care delivery for a specific group of clients through the use of practices based on EBP

Question 36

privacy rule
vs
security rule

Answer 36

privacy — protects personal privacy (client ID & PHI)

security–protects use 7 disclosure of ELECTRONIC pih

Question 37

how are breaches in privacy reported?

Answer 37

• MAIL
  *emergency—phone call
  *within 60 days

Question 38

adverse drug event
vs
medication error

Answer 38

ADE – injury caused my medical intervention linked to medicine

ME – preventable error capable of harm to client

Question 39

source oriented medical record

Answer 39

documentation divided into sections (ex: history, physical, notes)
**created separately by members of care team
***limited sharing of info