Nursing 100 Wcu assessment 1

infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host

What is included in the chain of infection?

Clostridium difficile, staphylococcus aureus

What is an example of infectious agents?

Table and bed

What is an example of a reservoir

Wound drainage, gi tract

What's an example of portal of exit?

Mouth, nose

What's an example of portal entry

susceptible host

a person likely to get an infection or disease, usually because body defenses are weak

Health care workers

clients

furniture

equipment

Which of the following factors are examples of reservoirs in the chain of infection ?

direct contact transmission

person to person transmission

indirect transmission

Occurs when microorganisms first are transmitted to an object or surface, and then are transferred to another person who touches those objects or surfaces

Coughing, sneezing, singing, and talking

What is an example of a droplet transmission?

Tuberculosis, measles, chickenpox

What is an example of an airborne transmission

inflammatory response

a reaction to tissue damage caused by injury or infection

incubation, prodromal, acute illness, period decline, convalescence

What are the stages of infection?

Incubation

an infection enters host and begins to mulitply

prodromal

the client begins having symptoms

Acute illness

manifestations of the specific infectious disease process are obvious and may become severe

Period of decline

signs and symptoms of the disease subside; patient is vulnerable to secondary infections

period of convalescence

the client returns to a normal or a "new normal" state of health

Local infections

confined to one area of the body, can be treated with topical antibiotics and oral antibiotics

Systemic infections

start as local infections and then spread to the bloodstream to infect the entire body

15-30 seconds, sing happy birthday

How long to wash hands

Medical asepsis

Cleaning technique practice that reduces the presence of disease causing

surgical asepsis

techniques used to destroy all pathogenic organisms, also called sterile technique

Standard precautions

Infection prevention practices that apply to all residents regardless of infection status

contact precautions

precautions used when a client has an infectious agent that can be transmitted by direct or indirect contact with body secretion; requires a min of gown and gloves prior to client interactions

systolic blood pressure

the point on the manometer at which the nurse hears the first Korotkoff sound is

diastolic pressure

The point on the nanometer at which the Koritkoff sounds are no longer audible is the

Tachycardia

pulse greater than 100 bpm

Bradycardia

slow heart rate (less than 60 bpm)

- central line-associated bloodstream infections

- catheter-associated unitary tract infections

- surgical site infections

- ventilator-assisted pneumonias

What are the four major HAIs

nursing interventions for hypertension

- encourage the client to adopt lifestyle interventions such as exercise, stress reduction, low-sodium diet, and weight loss if needed

- provide the client with information about anti hypertension medications, if prescribed by the provider, including expected adverse effects and when the provider should be notified.

nursing interventions for hypotension

- Increase fluids

- Place in an upright position unless medically contraindicated

- Evaluate the medications the client is taking

- Instruct the client about the risk for dizziness and falling

- Encourage the client to change positions slowly

- Avoid extremes in temperature

- Stay well hydrated

60 to 100 beats

What is the Normal pulse rate?

Grading of pulses

0: absent

1: weak and diminished (barely palpable)

2: normal (easily palpable)

3: full

4: strong and bounding

36 C and 38 c

96.8 F- 100.4 F

What is the expected body temp?

nursing interventions of hyperthermia

- give a tepid bath

- cool fluids

- cooler environment

- administer medications as ordered

Inspiration

Is the intake of air by the lungs in order to oxygenate body tissues and support cellular function

Expiration

Excels carbon dioxide from the lungs

12-20 breaths per minute

What is the expected rage for the respiratory rate?

oxygen saturation

95-100%

acute pain

pain that last seconds to less than 6 months

Chronic pain

pain continues for 6 months or longer and can be intermittent or continuous

- bacteria invade an open wound

- histamine, kinins, and prostaglandins arrive at the site

- plasma from the blood enter the site

- phagocytes occurs

- pus develops

What is the step of the inflammatory response?

Droplet precautions

should be in a private room

can be in the same room with a client who has the same infection

Airborne precautions

private room with door remained closed

airborne precautions examples

- client suspected of having tuberculosis

Contact precautions example

- client with a draining wound infected with MRSA

- client with frequent, large diarrheal stools and who is incontinent

droplet precautions

- client diagnosed with adenovirus

multidrug-resistant organisms (MDROs)

Organisms that have developed resistance to multiple antibiotics

- gown

- mask

- eye goggles or face shield

- gloves

What is the correct order for applying PPE?

- gloves

- face shied/ goggles

- mask

What is the correct order to remove PPE?

38 year old client who had a fever due to an infection

A nurse is reviewing the medical records for a group of clients. Which of the following clients should the nurse identify as being at risk for experiencing tachycardia

Preschooler who has a pulse of 142/min

A nurse is discussing tachycardia with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as exhibiting tachycardia?

provocative/palliative

quality

region/radiation

severity, timing

What does PQRST

Patient-controlled analgesia (PCA)

used typically for clients with postoperative pain. It is a computerized intravenous pump with a syringe of a prescribed opioid medicine usually morphine, fentanyl, or hydromorphone

Opioids or narcotic analgesics

considered first-line treatment for the management of moderate to severe pain/include all controlled substances, eg, morphine codeine, oxycodone, hydromorphone, methadone, meperidine

nonopioid

include acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) that are available over the counter

adjuvant analgesics

include antidepressants, anticonvulsants, corticosteroids, and bisphosphonates, used to enhance the effect of opioids by reducing pain and anxiety