ATI: Chapters 50-52

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kelc
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79532
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ATI: Chapters 50-52
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2011-04-14 01:11:01
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ati flashcards basic nursing care
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  1. When does an infection occur?
    When the presence of a pathogen leads to a chain of events - all components of the chain must be present for infection to occur
  2. What are the components of the chain of infection?
    • Infectious agent
    • Reservoir
    • Exit portal
    • Means of transmission
    • Entry portal
    • Susceptible host
  3. What are some examples of infectious agents?
    • Bacteria
    • Fungus
    • Virus
    • Protozoa
  4. What are some examples of reservoirs where infections can grow?
    • Wound drainage
    • Food
    • Oxygen tubing
  5. What are some exit portals for infectious agents?
    • Skin
    • Respiratory
    • GI tract
  6. What are some means of transmission for infectious agents?
    • Droplet
    • Person-to-person contact
    • Touching contaminated items
  7. The most common risks of infection are
    • Inadequate handwashing
    • Compromised health or defenses against infection
    • Poor medical or surgical asepsis by caregivers
    • Client with poor personal hygiene, poor nutrition
    • Stressed client
    • Older adult client
    • Clients making poor lifestyle choices
    • Clients recently exposed to poor sanitation, presence of mosquito-borne or parasitic diseases, or diseases endemic to the area visited but not in client's home country
  8. Who are some of the individuals that have compromised health or defenses against infection?
    • Immunocompromised
    • Post-surgical
    • Indwelling devices
    • Break in the skin
    • Poor oxygenation
    • Impaired circulation
    • Chronic or acute disease
  9. What are some poor lifestyle choices that put individuals at risk for infection?
    • IV drugs and sharing needles
    • Unprotected sex
  10. What is a nosocomial (hospital acquired) infection?
    An infection acquired while the client is in the health care system
  11. The best way to prevent nosocomial infections?
    Hand washing
  12. What is the most common site of nosocomial infections?
    Urinary tract
  13. What are the most common causative agents of nosocomial infections?
    Escherichia coli and Staphylococcus aureus
  14. Signs and symptoms of a generalized or systemic infection?
    • Fever
    • Increased pulse and respiratory rate
    • Malaise
    • Anorexia, nausea and/or vomiting
    • Enlarged lymph nodes
  15. Signs and symptoms of localized infection?
    • Redness
    • Edema
    • Pain or tenderness
    • Presence of exudates
    • Warmth of area on palpation
    • Loss of use of the affected part
  16. What laboratory results indicate infection?
    • Leukocytosis (WBCs > 11,000/uL)
    • Increases in the specific types of WBCs on differential
    • Elevated erythrocyte sedimentation rate (ESR)
    • Presence of microorganism on culture of the specific fluid/area
  17. What are some nursing diagnoses for infection?
    • Impaired tissue integrity
    • Risk for infection
    • Risk for social isolation
    • Risk for impaired tissue integrity
  18. What education should be provided to clients and their families to prevent infection?
    • Handwashing
    • Required and recommended immunizations
    • Good oral hygiene
    • Adequate amount of fluids
    • Pulmonary hygiene
  19. How does good oral hygiene prevent infection?
    Decreases the protein in the oral cavity which decreases the growth of microorganisms that can migrate through breaks in the oral mucosa
  20. How does adequate fluid intake prevent infection?
    • Prevents the stasis of urine by flushing the urinary tract and decreasing the growth of microorganisms
    • Keeps the skin from breaking down
  21. How does good pulmonary hygiene prevent infection?
    Decreases the growth of microorganisms and development of pneumonia by prevention of stasis of pulmonary excretions, stimulation of ciliary movement and clearance, and expansion of the lungs
  22. What are isolation guidelines?
    A group of actions that include hand hygiene and the use of barrier precautions, which are intended to reduce the transmission of infectious organisms
  23. When is personal protective equipment changed?
    • After contact with each client
    • Between procedures with the same client if in contact with large amounts of blood and body fluids
  24. What do standard precautions apply to?
    Apply to all body fluids, nonintact skin, or mucous membranes
  25. What precaution requires gloves to be worn when touching anything that has the potential to contaminate the hands?
    Standard precautions
  26. In standard precautions, when are masks, eye protection, or face shields required?
    When care may cause splashing or spraying of body fluids
  27. When are gowns worn on standard precautions?
    If the caregiver's clothes may be soiled during care
  28. What are the three types of transmission precautions?
    • Airborne
    • Droplet
    • Contact
  29. Which transmission precaution is to protect against droplet infections smaller than 5 um?
    Airborne
  30. What are some airborne transmitted infections?
    • Measles
    • Vericella
    • Pulmonary TB
    • Laryngeal TB
  31. Which transmission precaution requires a private room, mask/respiratory protection device for caregivers and visitors, and negative pressure airflow exchange in the room of at least six exchanges per hour
  32. Which transmission precaution is to protect against droplets larger than 5 um?
    Droplet
  33. What are some droplet transmitted infections?
    • Streptococcal pharyngitis or pneumonia
    • Meningococcal pneumonia/sepsis
    • Scarlet fever
    • Rubella
    • Pertussis
    • Mumps
    • Mycoplasma pneumonia
    • Pneumonic plague
  34. Which transmission precaution requires a private room or a room with other clients with the same infectious disease and a mask for providers and visitors?
    Droplet
  35. Which transmission precaution is to protect visitors and caregivers against direct client/environmental infections?
    Contact
  36. What are some direct contact transmitted infections?
    • RSV
    • Shigella
    • Enteric diseases
    • Wound infections
    • Herpes simplex
    • Scabies
    • Varicella zoster
    • Multi-drug resistant organisms
  37. Which transmission precaution requires a private room or room with other clients with the same infection, gloves and gowns worn by the caregivers and visitors, and disposal of infectious dressing material into a single, nonporous bag without touching the outside of the bag?
    Contact
  38. What are the guidelines for cleaning contaminated equipment?
    • Always wear gloves
    • Rinse first in cold water
    • Wast the article in hot water with soap
    • Use a brush or abrasive to clean corners or hard-to-reach areas
    • Rinse well in warm or hot water
    • Dry the article
    • Clean the equipment used in cleaning and the sink
    • Remove gloves and wash hands
  39. There are more than 60 communicable diseases that must be reported to the public health departments. What do the reports allow officials to do?
    • Ensure appropriate medical treatment of diseases
    • Monitor for common-source out breaks
    • Plan and evaluate control and prevention plans
    • Identify outbreaks and epidemics
    • Determine public health priorities based on trends
  40. Match the component of the chain of infection with the example of each component
    1. Infectious agent
    2. Reservoir
    3. Means of transmission
    4. Exit and entry portal
    5. Host

    A. Client
    B. Bacteria, virus, fungi, protozoa
    C. Wound drainage, food, oxygen tubing
    D. Person-to-person contact
    E. Skin, respiratory, and GI tracts
    • 1 - B
    • 2 - C
    • 3 - D
    • 4 - E
    • 5 - A
  41. Which of the following are reasons health care professionals are required to report communicable/infectious diseases? (select all that apply)
    - Planning and evaluating of control and prevention plans
    - Determining public health priorities
    - Ensuring proper medical treatment
    - Identifying endemic disease
    - Monitoring for common-source outbreaks
    • - Planning and evaluating of control and prevention plans
    • - Determining public health priorities
    • - Ensuring proper medical treatment
    • - Monitoring for common-source outbreaks
  42. What is the purpose of bathing?
    To cleanse the body, relax it and enhance healing
  43. What assessments should be performed when bathing a client?
    • Skin assessment
    • Wound assessment and wound care
  44. When are complete baths given?
    When the client is able to tolerate it and the client's hygiene needs warrant it (usually reserved for debilitated clients)
  45. When are partial baths given?
    When the client needs to only have odorous or uncomfortable areas cleansed or can perform part of the bath himself
  46. Why is foot care given?
    To prevent skin breakdown, pain and infection
  47. What clients is foot care extremely important for?
    Diabetic clients - must be done by a trained professional
  48. Why is perineal care important?
    To maintain skin integrity, relieve discomfort, and prevent transmission of infection
  49. Allowing the client to have as much control as possible over her hygiene does what for her psychologically?
    Shows respect for her dignity
  50. What are special considerations for older adult clients when giving hygiene care?
    • They have drier and thinner skin and may not tolerate as much bathing as a younger adult
    • They have a higher incidence of infection and periodontal disease
    • Dentures and partials must be fitted correctly
    • Dentures are a client's personal property and should never be left on a meal tray or in a place where they could be damaged
    • Dry mouth is common
    • May have poor nutritional status
  51. Why is dry mouth common in older adults?
    Due to decreased saliva production and medications used by this population
  52. What is poor nutritional status in the older adult often due to?
    • Dental problems
    • Socioeconomic status
    • Decrease in the ability to prepare healthy foods
  53. To understand how the client conducts hygiene at home and where the nurse will need to provide education and extra care, what needs to be assessed?
    Hygiene preferences
  54. What are some nursing diagnoses related to hygiene?
    • Risk for injury
    • Risk for infection
    • Bathing/self-care deficit
    • Dressing/grooming deficit
  55. What part of the client's body should be washed first when giving a bath?
    The face
  56. How should a bath be given?
    Systematically, staring with the client's upper body and continuing on to the lower extremities
  57. When performing perineum care, should the water be changed to fresh water?
    Yes
  58. After giving a client a bath, what needs to be documented?
    • Skin assessment
    • Type of bath
    • Client response
  59. How do you change and occupied bed?
    • - Roll the old bottom linens up in the bottom sheet or mattress pad under the client who is turned on his side, facing the opposite direction
    • - Apply clean bottom linens to the bed and smooth to the middle of the bed with the remainder of the linen fan folded underneath the client
    • - The client should roll over the linens and face the opposite direction while the nurse removes the old linens and applies the new linens
    • - Apply upper sheet and blanket
    • - Remove the pillow case by inserting the hand into the opening, grabbing the pillow and turning the pillowcase inside out
    • - Apply the clean pillow case by grasping the center of the closed end, turning the case inside out, fitting the pillow into the corner of the case adn pulling the case until it is right side out over the pillow
  60. What clients require gentle brushing and flossing when performing oral hygiene?
    Clients who have fragile oral mucosa
  61. How do you perform denture care for a client who is unable to do it himself?
    • - Remove the dentures with a gloved hand, pulling down and out at the front of the upper denture, and lifting up and out at the front of the lower denture
    • - Place dentures in a denture cup or emesis basin
    • - Brush them with a soft brush and denture cleaner
    • - Rinse them in water
    • - Store the dentures, or assist the client with reinserting them
  62. What instructions/education should be given to clients at risk for poor foot hygiene?
    • - Inspect feet daily, paying special attention to between the toes
    • - Use lukewarm water and dry the feet thoroughly
    • - Apply moisturizer to the feet but avoid applying it between the toes
    • - Avoid OTC products that contain alcohol or other strong chemicals
    • - Wear clean cotton socks daily
    • - Check shoes for any objects that may cause injury
    • - Cut nails straight across and use emery board to file edges
    • - Avoid self-treating corns or calluses
    • - Buy and wear comfortable shoes that do not cut off circulation
    • - Avoid using heat applications
    • - Contact PCP if any signs of infection or inflammation appear
  63. What are the principles of perineal care?
    • - Providing privacy
    • - Maintaining a professional demeanor
    • - Removing fecal material away from the skin if present
    • - Cleansing the client from front to back
    • - Drying thoroughly
    • - Retracting the foreskin in male clients to wash the tip of the penis, then replace the foreskin
  64. What is done when providing nail care?
    • Assess the client's nails for size, shape, and condition of nail beds
    • Assess for cracking, clubbing or any fungus that may be present
    • Use caution and have proper training when cutting nails
  65. Who can trim the nails and provide foot care for diabetic clients?
    Only the PCP or trained specialist
  66. What type of razor should clients prone to bleeding or receiving anticoagulants use?
    Electric razor
  67. When shaving a client with a razor blade, what does the nurse do?
    • Apply soap or shaving cream to warm, moist skin
    • Move the razor over the skin the direction of hair growth using short strokes
  68. A client is transferred from a long-term care facility to an acute care setting. An indwelling Foley catheter was inserted just prior to transfer. Which of the following tasks will help prevent the development of a nosocomial infection?
    A. Assessing the client's ability to void independently
    B. Properly hydrating the client and giving her a diet high in fiber to prevent constipation
    C. Placing an absorbent pad under the client to protect the bed in case of incontinence
    D. Frequently cleaning the client's perineal area and properly caring for the catheter
    D. Frequently cleaning the client's perineal area and properly caring for the catheter
    (this multiple choice question has been scrambled)
  69. Which of the following are appropriate teaching measures related to care of the feet for a client with diabetes mellitus? (select all that apply)
    - inspect feet daily
    - use moisturizing lotions on feet
    - wash with warm water and let air dry
    - use OTC products to treat abrasions
    - check shoes for any foreign objects
    • - inspect feet daily
    • - use moisturizing lotions on feet
    • - check shoes for any foreign objects
  70. A client is in balanced suspension traction following a motor vehicle crash. He is unable to perform his own personal hygiene and must have it performed by the nurse. Which of the following factors will have the most influence on his comfort level?
    A. amount of pain medicine he received
    B. gender of the nurse
    C. client's position
    D. attitude of the nurse
    D. attitude of the nurse
    (this multiple choice question has been scrambled)
  71. A client experiences dyspnea and reports feeling tired after completing her morning care. Which of the following should the nurse include in the client's plan of care for the next day?
    A. ask a family member to come in and give the client a bath
    B. plan for several rest periods during morning care
    C. do not offer any morning care
    D. perform all of the client's care as quickly as possible
    B. plan for several rest periods during morning care
    (this multiple choice question has been scrambled)
  72. What clients are at risk from heat/cold applications?
    • Very young
    • Fair skinned
    • Older adults
    • Immobile
    • Impaired sensory perceptions
  73. Why should long applications of either heat or cold be avoided?
    They will result in the opposite reaction from the desired response
  74. When using heat, why do bony prominences need to be monitored carefully?
    They are more sensitive to heat applications
  75. Why should heat applications be avoided over metal devices (pacemakers; artificial joints)?
    To prevent deep tissue burns
  76. Why should heat not be applied to the abdomen of a pregnant woman?
    To avoid harm to the baby
  77. Should a heat application be placed under an immobile client?
    No because it may increase the risk of burns
  78. When are cold applications inappropriate?
    For clients with cold intolerance, vascular insufficiency, and conditions aggravated by cold (Raynaud's phenomenon)
  79. The order for heat/cold applications must include?
    • Location
    • Duration and frequency
    • Specific type
    • Temperature to use
  80. What are some nursing diagnoses related to heat/cold therapy?
    • Acute/chronic pain
    • Risk for injury
    • Risk for impaired skin integrity
  81. What are the types of heat applications?
    • Moist
    • Dry
  82. What are the types of moist heat applications?
    • Hot compresses
    • Hot soaks
    • Sitz baths
  83. What are the types of dry heat applications?
    • Hot pack
    • Aquathermia pad
    • Warming blanket
  84. What are the supplies needed for a hot compress?
    • Towel
    • Bath thermometer
    • Hot water
    • Plastic covering
    • Hot pack or aquathermia pad
    • Tape
  85. What are the supplies needed for hot soaks?
    • Water
    • Bath thermometer
    • Basin
    • Waterproof pads
  86. What are the supplies needed for a sitz bath?
    • Sitz bath (disposable or built in)
    • Bath thermometer
    • Bath blanket
    • Towels
  87. What are the two types of cold applications?
    • Moist
    • Dry
  88. What supplies are needed for a moist cold application?
    • Large basin of ice
    • Cold water
    • Cold pack to be used in place of ice
  89. What supplies are need for a dry cold application?
    • Ice bag, ice collar, ice glove or a cold pack
    • Cooling blanket
  90. When giving cold/heat applications, the site needs to be assessed every __ to ___ min
    5; 10
  91. When assessing sites undergoing heat/cold therapy what needs to be assessed for and what should be done if any of these are found?
    • Redness or pallor
    • Pain or burning
    • Numbness
    • Shivering
    • Blisters
    • Decreased sensations
    • Cyanosis
    • Discontinue the application if any of the above occur
  92. What needs to be documented for heat/cold applications?
    • Location, type and length of application
    • Condition of the skin prior to and after the application
    • The client's ability to tolerate the application
  93. Which of the following clients would benefit from the application of cold? (select all that apply)
    - a 45 y/o client with a sprained ankle
    - a 27 y/o client with Raynaud's phenomenon
    - a 62 y/o client who just had a knee replacement surgery
    - a 35 y/o client with a toothache
    - a 10 y/o client with a nosebleed
    • - a 45 y/o client with a sprained ankle
    • - a 62 y/o client who just had a knee replacement surgery
    • - a 35 y/o client with a toothache
    • - a 10 y/o client with a nosebleed
  94. A nurse is conducting morning rounds and notices an immobile client lying on an aquathermia pad. Which of the following nursing interventions is the most important for the nurse to include in the morning assessment?
    A. pain assessment to determine the client's level of pain
    B. evaluation of the heating pad to check for a malfunction
    C. the client's ability to express if treatment is eliminating pain
    D. a thorough skin assessment to check for skin damage
    D. a thorough skin assessment to check for skin damage
    (this multiple choice question has been scrambled)
  95. True or false: moist cold compresses are left in place for at least 45 min
    False: heat and cold applications are kept in place for 15 to 20 min
  96. True or false: cyanosis is a complication of cold applications
    True
  97. True or false: heat applications increase muscle tension
    False: heat applications cause muscle relaxation

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