NUR 215 Exam #2 with 100% accurate solutions + rationales 2026-2027

what is an infection

invasion of and multiplication of a pathogen in the body

transmission chain of infection order

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

Types of pathogens

viruses, bacteria, parasites, fungi

HAI

hospital acquired infection

common HAI associated with a central line

Central line associated bloodstream infections (CLABSI)

common HAI causing severe diarrhea

Clostridium difficile infections (C. diff)

common HAI affecting the lungs

pneumonia

common HAI that is treatment resistant

Methicillin-resistant staphylococcus aureus (MRSA) infections

common HAI post-op

surgical site infections

common HAI related to catheterization

catheter associated urinary tract infections

stages of infection

incubation, prodromal, illness, decline, convalescence

incubation stage of infection includes

interval between pathogen entering body and presentation of first symptoms

prodromal stage of infection includes

interval from onset of general symptoms to more distinct findings; pathogen multiplies

illness stage of an infection

interval when findings specific to the infection occur

decline stage of an infection includes

immune defenses were successful in reducing the # of pathogens

convalescence stage of infection includes

interval when acute findings disappear, total recovery taking days to months

local infection definition

occurs in a region of the body

Local infection symptoms

edema, pain, erythema, and warmth in area

systemic infection definition

widespread infection in many systems of the body; often travels in the blood or lymph

systemic infection symptoms

fever, chills, malaise, fatigue, increase RR and HR

primary infection definition

initial infection within a given patient

secondary infection definition

infections that follow a primary infection; often by opportunistic pathogens

Risks for infection

failure to follow asepsis, PT has poor hygiene, poor nutrition, tobacco use, excessive alcohol use, high stress, live in a crowded environment

factors that compromise health or defense against infection

immunocompromised, indwelling devices, break in skin, poor oxygenation/impaired circulation, chronic or acute disease

Infection assessment findings

fever, chills, high HR, high RR, malaise, fatigue, anorexia, nausea/vomiting, diarrhea/ABD cramping, enlarged lymph nodes

older adult infection assessment considerations

agitation, confusion, incontinence

infection lab findings

leukocytosis, left shift, elevated ESR, culture present for specific microbe

leukocytosis is?

high WBC; WBC>10,000

left shift is?

increase in band neutrophils (a type of WBC)

elevated ESR is?

erythrocyte sedimentation rate >20mm/hr indicative of inflammation

How to break the chain of infection

hand hygiene, immunization education, oral hygiene education, pulmonary hygiene, clean equipment between PTs

isolation guidelines

change PPE after contact w/ each PT and between procedures w/ same PT

dangers of isolating PTs

PT is high risk for developing depression and loneliness

Standard Precautions applies to

all body fluids (except sweat), non intact skin, and mucous membranes.

standard precautions include

hand hygiene, gown and gloves is soil likely, mask and eye cover is splashing of bodily fluids is likely, sharps etiquette, cough etiquette

common contact precaution infections

MRSA, VRE, diarrheal illnesses, open wounds, RSV, scabies

contact precautions include

transmission within 3 ft of PT through direct and indirect contact, gloves, gown, PT dedicated/disposable equipment, cover draining wounds for PT transfer

droplet precautions infections

pneumonia, influenza, whooping cough/pertussis, meningitis

droplet precautions include

transmitted by droplets >5 microns within 3-6 feet of PT, surgical mask and face shield always, gown and gloves and eye covering if secretion contact likely, PT wears mask during transport

airborne precautions are for

TB, measles, varicella

airborne precautions include

transfer through droplets <5 microns anywhere in room, always use gloves, gowns, respirators, and eye protection; PT in negative pressure room

protective environment is for

immunocompromised PTs; ex: allogenic hematopoietic stem cell transplant

protective environment precautions

Private room; positive airflow with 12 or more air exchanges per hour; HEPA filtration for incoming air; mask to be worn by patient when out of room, no live plants or flowers

PPE includes

Gloves, surgical masks, protective eye wear, face shields, and protective clothing, respirator

PPE Donning order

hand hygiene, gown, maks, goggles, gloves

PPE doffing order

gloves, gown, goggle, mask, hand hygiene

Hygiene definition

cleanliness that is conducive to the preservation of health

ADLs include

bathing, ambulation, toileting, transfers, eating, dressing

Benefits of hygiene

promotes comfort and health, improves self-image, decreases infection and disease, aids in social interaction

cultural influences of hygiene

some cultures have differing beliefs surrounding hygiene and cleanliness; ex: orthodox Judaism prohibits inter-sex personal care

Rights of Delegation

right task, right circumstances, right person, right direction/communication, right supervision

factors affecting hygiene and self care

personal preferences, culture and religion/spirituality, economic status, developmental level, knowledge level, health status (cognitive impairments, emotional disturbances, pain, mobility, sensory deficits, visual deficits)

dentures nursing interventions steps

remove upper dentures down and out, remove lower dentures up and out, assess PT's mouth, store in solution labeled w/ PT's name, place wash cloth at basin of sink, use tepid water, assess for sharp edges, clean dentures with denture cleaner, rinse PT's mouth w/ mouthwash, replace dentures w/ adhesive, assess comfort

unconscious PT oral care nursing interventions

ensure suction is set up and functioning, side lying position at 15-30 degree angle to prevent aspiration, tongue depressor or bite block, use chlorihexidine swabs, do not use lemon glycerine swabs

what equipment can be used for hair care

no-rinse shampoo cap, inflatable shampoo basin, shampoo tray with a spout to allow water to drain away from head

Skin care nursing interventions

wash eyes from inner canthus to outer canthus, no soap on face, on body use soapy water then rinse with just water, apply lotion to dry areas, older adults may only tolerate bath 2x/week, long firm strokes on body unless risk for PE, start from least soiled areas to most soiled areas, assess skin for lesions and integrity

nail care

look for size, shape, cracking, clubbing, fungus

diabetes foot care

wash feet in warm water everyday, dry feet well, keep skin supple, inspect feet every day, no clipping toe nails, keep feet warm and dry, never walk barefoot, examine shoes every day

sensory systems

vision, hearing, taste, smell, touch

ADL assessment should focus on

ability not quality

self-neglect

PT is capable of self care but fails to maintain hygiene to society's standards

assess skin for

color, hydration, texture, turgor, lesions

assess gums for

dryness, inflammation, pain

assess feet/nails for

shape, size, lesions, dryness, irritation, bilateral pulse, cracking, clubbing, fungus

nursing diagnoses for ADL assessment

bathing/hygiene deficit, dressing/grooming deficit, feeding deficit, toileting deficit, self neglect

pruritus definition

itching; may lead to skin lascerations

dry skin may lead to

cracks, burning, itching

Excoriation definition

loss of superficial layers of skin; can be caused by scratching or digestive enzymes found of fecal matter

Maceration definition

tissue softened by prolonged moisture; skin is susceptible to damage

Abrasion Definition

loss of superficial layer of skin; caused by friction or trauma

pressure injury definition

lesions caused by tissue compression and inadequate perfusion

acne definition

inflammation of sebaceous glands

burn definition

traumatic injury caused by thermal, electrical, chemical, or radioactive agents

risks for impaired tissue integrity

dampness, dehydration, nutrition status, insufficient circulation, skin diseases, jaundice, life style and personal choices

SIIR

skin integrity impairment risk; nursing diagnosis for risk for alteration of dermis or epidermis

SII

skin integrity impairment; nursing diagnosis for impaired ability to maintain integument

assist bath

PT just needs help with hard to reach areas and getting into bath/shower

complete bath

nurse washes PT's whole body

partial bed bath

pits and bits

Dementia PT bath

focus on PT, distract PT, gentle pressure, be creative, regular time every day, continuity of care, privacy, avoid sensory overload, foster independence, simple explanations, inform before action, NO RUSH, teach at home care givers, re-orient

Common foot problems: corn

cone shaped thickening of epidermis from pressure over bony area of feet

common foot problems: calluses

painless thickening over weight bearing area of foot

common foot problems: tinea pedis

athlete's foot/ fungal skin infection; itching, burning, blisters, scaling, cracking

common foot problems: ingrown toenail

result of improper toenail trimming or poor fitting shoes. can be spontaneous

common foot problems: foot odor

microbes interact with sweat

common foot problems: plantar warts

painful growth on sole of foot caused by a virus

common foot problems: pressure injuries

bony prominence with longterm pressure. common on heels, toes, and ankles

common foot problems: bunions

enlarged first metatarsal joint causing toes to progressively start leaning

common mouth problems: dental caries

cavities from plaque and tartar build-up

common mouth problems: periodontal disease

major cause of tooth loss on adults over 35, bleeding and receding gums, destruction of surrounding bone structures

common mouth problems: gingivitis

inflammation of gums, may progress into periodontal disease if left untreated

common mouth problems: halitosis

bad breath from poor oral hygiene, certain foods, tobacco, cavities, infections, or systemic diseases

common mouth problems: stomatitis

inflammation of oral mucosa from bacteria, trauma, irritations, nutritional deficiencies, systemic infection

common mouth problems: glossitis

tongue inflammation from deficiencies in vit B12, folic acid, and iron

common mouth problems: Cheilosis

cracking of lips usually from B complex deficiencies

common mouth problems: oral malignancies

lumps, ulcers, white/red patches, bleeding, pain, persistent sores, numbness

common mouth problems: thrush

candida infection in mouth

common hair problems: dandruff

excessive scalp epidermal shedding

common hair problems: pediculosis

head lice

common hair problems: alopecia

hair loss, gradual or sudden; causes = autoimmune disorder, hormonal imbalance, thyroid disease, stress, fever, some meds, chemotherapy