NURSING 215 STUDY GUIDE MODULE 2 EXAM

Questions and Answers

Which of the following is the most effective method to prevent the transmission of infections in a healthcare setting?

Administering vaccines to all staff members

Isolating all patients with infections

Using frequent and effective hand hygiene (correct)

Wearing a mask at all times

What should a nurse educate a patient about to help prevent urinary tract infections?

Increasing fluid intake (correct)

Using antibiotics routinely

Limiting fruit consumption

Engaging in regular physical exercise

Which of the following actions is appropriate for a nurse when caring for an immobile patient to prevent infections?

Turning the patient every 4 hours

Administering antibiotics every day

Encouraging deep breathing and coughing exercises (correct)

Limiting patient movement to reduce fatigue

What is the correct distance a nurse should maintain from a patient who is coughing, to minimize droplet transmission?

3 feet Signup and view all the answers

Which factor is considered a risk for increasing a patient's susceptibility to infection?

Experiencing a nutritional deficiency Signup and view all the answers

Which of the following is NOT a recognized mode of transmission for infections?

Congenital transmission Signup and view all the answers

Which precaution is necessary to prevent droplet transmission of infections?

Covering the mouth and nose with a tissue or mask when sneezing Signup and view all the answers

Inadequate hygiene practices can primarily lead to increased susceptibility in which type of host?

Compromised host Signup and view all the answers

Which portal of exit is associated with infections transmitted via the respiratory tract?

Respiratory tract Signup and view all the answers

What is a key factor that enhances the risk of infection transmission in crowded environments?

Higher likelihood of close contact among individuals Signup and view all the answers

Which one of the following is a potential portal of entry for a pathogen?

All of the above Signup and view all the answers

What condition is likely to make a person a susceptible host for infections?

Chronic illness like diabetes Signup and view all the answers

Which causative agent is most commonly associated with direct contact transmission?

HIV Signup and view all the answers

Which mode of transmission requires protective measures against droplets larger than 5 mcg?

Droplet Signup and view all the answers

What is the primary purpose of protective precautions?

To safeguard immunocompromised individuals Signup and view all the answers

Which of the following supplies is required for airborne precautions?

Mask and private room Signup and view all the answers

What distinguishes airborne transmission precautions from droplet transmission precautions?

Airborne precautions cover infections smaller than 5 mcg, while droplet is larger than 5 mcg. Signup and view all the answers

Which personal protective equipment is essential when treating contact infection cases?

Gowns and gloves Signup and view all the answers

Which of the following is NOT characteristic of a contact precaution?

A private room is mandatory at all times Signup and view all the answers

What is a critical factor when managing patients under airborne precautions?

Ensuring at least 6-12 air exchanges per hour Signup and view all the answers

What is the required action for a patient with an airborne infection when outside their room?

Wearing a mask designed for airborne precautions Signup and view all the answers

Which of the following is a factor that can make an individual a susceptible host for infection?

Recent surgical procedures Signup and view all the answers

What is the primary causative agent of infections that can be transmitted through respiratory droplets?

Viruses Signup and view all the answers

Which portal of exit involves transmission through skin or mucous membranes?

Blood/body fluids Signup and view all the answers

Which transmission mode includes touching a contaminated surface and then touching the mouth or nose?

Fecal-oral transmission Signup and view all the answers

Which environmental condition increases the risk of infection for individuals living in it?

Living in a crowded environment Signup and view all the answers

What is the role of a reservoir in the transmission chain of infection?

It provides the necessary conditions for pathogens to survive. Signup and view all the answers

Which of the following conditions may lead to impaired circulation, thus increasing susceptibility to infections?

Chronic lung disease Signup and view all the answers

Which of the following is NOT a recognized causative agent of infection?

Antibodies Signup and view all the answers

Which approach is best for communicating with a patient who has hearing loss?

Sit facing the patient and speak slowly and clearly Signup and view all the answers

What is an important safety measure to implement for patients with sensory deficits?

Ensure IV poles and drainage tubes are easy to maneuver Signup and view all the answers

How should a healthcare provider interact with a patient experiencing aphasia?

Use clear, slow speech and allow time for the patient to respond Signup and view all the answers

What is a recommended strategy when caring for a patient with vision loss?

Explain interventions before touching the patient Signup and view all the answers

Which technique is most effective for helping a disoriented patient regain their bearings?

Call the patient by name and maintain eye contact at eye level Signup and view all the answers

What is the essence of active listening in therapeutic communication?

Being attentive to verbal and nonverbal cues from the patient Signup and view all the answers

Which technique involves commenting on the patient's appearance or behavior?

Sharing Observations Signup and view all the answers

How does sharing hope in communication benefit the patient?

It provides a sense of possibility and encouragement. Signup and view all the answers

Which communication technique is identified as the most potent form of communication?

Using Touch Signup and view all the answers

What is the primary purpose of the clarifying technique during therapeutic communication?

To check understanding and ensure accurate communication Signup and view all the answers

What role does summarizing play in therapeutic communication?

To document key aspects of the interaction and provide closure Signup and view all the answers

How does self-disclosure in therapeutic communication serve a purpose?

By emphasizing similarities or differences in experiences for connection Signup and view all the answers

What is the goal of using open-ended questions in therapeutic communication?

To allow free expression and gather more information Signup and view all the answers

What is the appropriate use of confrontation in therapeutic communication?

To raise awareness of inconsistencies after trust has been established Signup and view all the answers

What is the primary benefit of allowing silence during patient interactions?

To give time for reflection and processing of information Signup and view all the answers

What is a common indicator of salicylism that should be monitored in a client with a healthy liver?

Tinnitus Signup and view all the answers

Which action should be taken to prevent gastric upset when administering NSAIDs?

Administer with food or antacids Signup and view all the answers

What is a serious side effect of opioid medication that requires monitoring?

Respiratory depression Signup and view all the answers

Which of the following is an appropriate intervention for a patient experiencing sedation from opioids?

Monitor level of consciousness and take safety precautions Signup and view all the answers

What should be monitored to prevent complications related to urinary retention in patients receiving opioids?

Intake and output Signup and view all the answers

Which medication can be administered to alleviate constipation caused by opioids?

Stool softeners Signup and view all the answers

What is the primary benefit of using a PCA (Patient-Controlled Analgesia) pump?

It allows patients to administer their own pain medication safely. Signup and view all the answers

Which sensory deficit can occur due to a gradual decrease in sensory input?

Conductive hearing loss Signup and view all the answers

What is a common visual impairment that can contribute to sensory deficits?

Cataracts Signup and view all the answers

What condition is associated with a gradual loss of vision due to degeneration of the retina?

Macular degeneration Signup and view all the answers

Which of the following situations requires hand washing before patient care?

Patient has diarrhea Signup and view all the answers

What is the correct duration for hand washing to ensure effective hygiene?

30 seconds Signup and view all the answers

What should be done to prevent aspiration for an unconscious patient during oral care?

Ensure suction equipment is ready Signup and view all the answers

What is the correct method for removing upper dentures?

Pull down and out the front Signup and view all the answers

How should dentures be brushed to ensure proper care?

In horizontal back-and-forth motion Signup and view all the answers

Why is it important to store dentures in water?

To ensure they stay moist Signup and view all the answers

What is the primary goal of foot care in patient hygiene?

To minimize infection and pain Signup and view all the answers

What should be checked prior to oral care for a patient at risk of aspiration?

Presence of gag reflex Signup and view all the answers

What position should unconscious patients be placed in to prevent aspiration during oral care?

Semi-Fowler's position Signup and view all the answers

What is the ideal cleaning method for maintaining dentures?

Soft brush and denture cleaner Signup and view all the answers

What footwear is recommended for someone with peripheral neuropathy to maintain safety?

Well-fitting, protective shoes Signup and view all the answers

Which of the following is NOT one of the five rights of delegation?

Right Timing Signup and view all the answers

Which assessment tool would be suitable for assessing pain in patients with advanced dementia?

Pain Assessment in Advanced Dementia Scale (PAINAD) Signup and view all the answers

What is a crucial practice to ensure the safety of individuals with peripheral neuropathy regarding foot care?

Inspect feet often Signup and view all the answers

What is included in the tasks that can be delegated to Unlicensed Assistive Personnel (UAP)?

Taking vital signs on a stable patient Signup and view all the answers

Which right focuses on ensuring the person assigned the task is qualified to perform it?

Right Person Signup and view all the answers

Which statement about alcohol consumption for individuals with peripheral neuropathy is correct?

Avoiding alcohol is recommended Signup and view all the answers

Which type of hearing loss is characterized by issues with the inner ear or auditory nerve?

Sensorineural hearing loss Signup and view all the answers

What is a primary reason for bathing a patient?

To provide relaxation and enhance healing Signup and view all the answers

What task is typically NOT appropriate to delegate to UAP?

Assessing a new patient's condition Signup and view all the answers

Which of the following aspects is NOT part of the Right Circumstance in delegation?

The caregiver’s availability Signup and view all the answers

In which situation is it appropriate to delegate turning a patient?

When the patient is stable and at low risk Signup and view all the answers

Which of the following is an example of a task that cannot be delegated to UAP?

Conducting a patient assessment Signup and view all the answers

What is a primary characteristic of acute pain?

It is protective and self-limiting. Signup and view all the answers

Which of the following symptoms is typically associated with acute pain?

Tachycardia Signup and view all the answers

Which type of pain lasts longer than six months and does not resolve with tissue healing?

Chronic pain Signup and view all the answers

What is a common consequence of improperly managed acute pain?

Chronic pain Signup and view all the answers

Which nonpharmacological measure primarily involves distracting the patient from pain?

Distraction techniques Signup and view all the answers

Which treatment approach is most common for managing chronic pain?

Symptomatic relief Signup and view all the answers

Which pharmacological class of analgesics is known for its hepatotoxic effects?

Non-opioids Signup and view all the answers

What can psychological implications of chronic pain lead to?

Disability and impaired functioning Signup and view all the answers

What type of chronic pain occurs without a known cause?

Idiopathic pain Signup and view all the answers

What is an example of a cognitive-behavioral measure for pain management?

Imagery techniques Signup and view all the answers

Which approach is typically employed for the management of chronic pain?

Long-acting or controlled-release opioids Signup and view all the answers

Which intervention is specifically used to promote venous return in patients with edema?

Elevation of edematous extremities Signup and view all the answers

How does cold therapy primarily help manage pain?

Interrupts pain pathways Signup and view all the answers

What physiological responses are typically absent in chronic pain patients?

Vital sign fluctuations Signup and view all the answers

Which of the following describes a symptom associated with postictal state following a seizure?

Confusion and fatigue Signup and view all the answers

Which relaxation technique is specifically recognized for its tactile approach?

Massage Signup and view all the answers

What common pain intervention involves using needles to stimulate specific points?

Acupuncture Signup and view all the answers

Which of the following methods is least likely to be classified as a nonpharmacological pain intervention?

Opioid medication Signup and view all the answers

What is the focus of cognitive-behavioral strategies for pain management?

Changing pain perception Signup and view all the answers

Which nonpharmacological pain intervention uses a combination of techniques to promote relaxation?

Cognitive-behavioral methods and relaxation Signup and view all the answers

What is the appropriate action to take after a patient uses the bathroom to ensure proper hygiene?

Perform hand hygiene for at least 30 seconds Signup and view all the answers

Which of the following steps is essential when providing oral care to a patient at risk of aspiration?

Have suction equipment ready at the bedside Signup and view all the answers

What is the best method for cleaning dentures according to care guidelines?

Use a horizontal back-and-forth motion with a soft brush Signup and view all the answers

What signifies the appropriate way to store dentures when not in use?

In a denture cup with the patient's name labeled Signup and view all the answers

When providing foot care, what is a critical consideration to prevent complications?

Checking for signs of infection and pain Signup and view all the answers

Which situation necessitates immediate hand washing instead of using hand sanitizer?

After caring for a patient with diarrhea Signup and view all the answers

What action should be taken when caring for a patient with oral mucosa health issues?

Use gentle brushing and flossing techniques Signup and view all the answers

How should dentures be removed from a patient’s mouth?

Following a pulling down and out method for the upper denture Signup and view all the answers

Which position is recommended for a patient during oral care to reduce aspiration risk?

In a sitting position Signup and view all the answers

What should be done if a patient is unconscious and requires oral care?

Ensure suction equipment is ready Signup and view all the answers

Which of the following is considered a risk factor for increased susceptibility to infections related to inadequate health defenses?

Recent surgery Signup and view all the answers

Which of the following correctly describes a mode of transmission for infections?

Droplet transmission from sneezing and coughing Signup and view all the answers

Which causal agent is specifically linked with transmission through indirect contact?

Salmonella enteritidis Signup and view all the answers

What is a common portal of exit for pathogens that spread through the gastrointestinal tract?

Fecal matter Signup and view all the answers

Which population is at elevated risk due to environmental factors that contribute to infection susceptibility?

Clients in crowded environments Signup and view all the answers

Which of the following best describes a susceptible host in the context of infection transmission?

A patient with broken skin and chronic conditions Signup and view all the answers

What is an example of a reservoir in the chain of infection?

Contaminated surfaces Signup and view all the answers

Which factor does NOT contribute to the transmission chain of infection?

Patient adherence to treatment Signup and view all the answers

Which symptom is indicative of salicylism that a client with a healthy liver should monitor for?

Tinnitus Signup and view all the answers

What is the most appropriate intervention to prevent gastric upset when administering NSAIDs?

Administer with food or antacids Signup and view all the answers

Which critical sign should be monitored to assess for potential respiratory depression in a patient receiving opioids?

Respiratory rate Signup and view all the answers

What is an appropriate advice for a client experiencing light-headedness due to orthostatic hypotension?

Sit or lie down until symptoms resolve Signup and view all the answers

Which medication can be used to treat constipation resulting from opioid use?

Docusate Signup and view all the answers

What type of pain is characterized by throbbing or aching sensations and localized intensity?

Somatic pain Signup and view all the answers

Which type of pain results from abnormal or damaged pain nerves?

Neuropathic pain Signup and view all the answers

What type of pain can be described as intense, shooting, or burning, and can include symptoms like 'pins and needles'?

Neuropathic pain Signup and view all the answers

Which type of pain is commonly associated with internal organs and can cause referred pain in other areas of the body?

Visceral pain Signup and view all the answers

Which medications are primarily effective for the relief of nociceptive pain?

Opioids and non-opioid medications Signup and view all the answers

What is the primary consideration when performing oral care for a patient with an impaired gag reflex?

Ensure suction equipment is ready at bedside Signup and view all the answers

Which type of medications can provide relief for peripheral neuropathic pain?

Adjuvant medications such as antidepressants Signup and view all the answers

What is the correct method for removing dentures from a patient's mouth?

Lifting up and out the front of the upper denture first Signup and view all the answers

Pain that arises from structures in bones, joints, muscles, and skin falls under which category?

Somatic pain Signup and view all the answers

What is a common characteristic of nociceptive pain?

It is typically described as localized and throbbing. Signup and view all the answers

How long should hands be washed to ensure proper hygiene?

30 seconds Signup and view all the answers

What precaution should be taken when providing foot care to prevent injury?

Inspecting feet regularly for wounds or infections Signup and view all the answers

Which type of pain is often treated with muscle relaxants and antispasmodics?

Neuropathic pain Signup and view all the answers

Referred pain suggests that pain experienced in one area may originate from which body parts?

Internal organs separate from the stimulus Signup and view all the answers

Which technique is recommended for brushing dentures?

HORIZONTAL back-and-forth motion with a soft brush Signup and view all the answers

When should hand hygiene be performed regarding patient conditions?

After any patient interaction and when the patient has diarrhea Signup and view all the answers

What should be done to store dentures properly?

Keep them in a labeled denture cup filled with water Signup and view all the answers

What is the best position for a patient receiving oral care to reduce aspiration risk?

On their side or in a semi-fowler's position Signup and view all the answers

Regarding denture cleaning, what is the appropriate method?

Using denture cleaner with a soft brush Signup and view all the answers

Which of the following is essential when caring for patients with oral mucosa concerns?

Gentle brushing and careful flossing are necessary Signup and view all the answers

What should be avoided during a seizure to ensure the safety of the patient?

Restraining the patient's limbs Signup and view all the answers

What is the first action to take immediately after a seizure has ended?

Determine the patient's mental status Signup and view all the answers

Which action is appropriate for a caregiver when shampooing an immobile patient?

Lift the patient's head to wash the back of the head Signup and view all the answers

What is the purpose of using a wider-toothed comb or hair pick when grooming?

To minimize scalp injury or trauma Signup and view all the answers

What is a recommended practice for ensuring oxygenation during a seizure?

Keep suction equipment readily available for use during the seizure Signup and view all the answers

What are the appropriate items to have available as rescue equipment during a seizure?

Padding, oxygen, and suction Signup and view all the answers

Which option describes an alternative method for washing hair when a patient is bedridden?

Implement a dry or no-rinse shampoo method Signup and view all the answers

How should you position the patient when preparing to shampoo their hair in the sink?

In a supported seated position with a towel behind their neck Signup and view all the answers

What should a caregiver do immediately before an impending seizure?

Ensure the area is free of hazards Signup and view all the answers

Which statement about patient grooming practices is true regarding cultural considerations?

Customs may vary and should not be disregarded. Signup and view all the answers

What is the primary purpose of giving a therapeutic bath?

To provide comfort and treatment for specific conditions Signup and view all the answers

When washing a patient, in which order should the body parts be cleansed according to best practices?

Face, upper extremities, lower extremities Signup and view all the answers

Why is meticulous oral hygiene particularly important for certain patient populations?

It prevents the transmission of pathogens that can cause pneumonia Signup and view all the answers

Which of the following statements about foot care for diabetic patients is true?

Qualified professionals must perform it to prevent complications. Signup and view all the answers

What should be done if the bath water becomes cold during a bed bath?

Request warmer water to replace it. Signup and view all the answers

What is a recommended technique when washing lower extremities for patients with a history of DVT?

Wash from distal to proximal with light strokes. Signup and view all the answers

What is an essential action to take before beginning a bed bath procedure?

Lock the wheels of the bed. Signup and view all the answers

What is necessary when cleaning a patient's perineal area during a bed bath?

Ensure gloves are worn and maintain patient dignity. Signup and view all the answers

How should a patient who can partially bathe themselves be assisted?

Encourage independence while assisting with hard-to-reach areas. Signup and view all the answers

What is the primary reason for professionals to perform foot care for clients with diabetes or peripheral vascular disease?

To evaluate feet and prevent injury Signup and view all the answers

Which of the following practices should be avoided when providing foot care to at-risk clients?

Applying lotion between the toes Signup and view all the answers

When cutting nails for a patient with diabetes, what is the correct protocol to follow?

Cut nails only if directed by a physician or specialist Signup and view all the answers

What should a patient at risk for foot injuries do before wearing shoes?

Check shoes for any objects or rough seams Signup and view all the answers

Why is it recommended to avoid soaking feet in patients with diabetes or peripheral vascular disease?

It raises the risk of skin infections Signup and view all the answers

What type of lotion should be avoided when moisturizing feet?

Lotions containing alcohol or strong chemicals Signup and view all the answers

Which of the following should patients avoid when managing corns or calluses?

Self-treating with over-the-counter products Signup and view all the answers

What is a significant aspect of foot and nail care in patients with diabetes or peripheral vascular disease?

Filing toenails instead of cutting them Signup and view all the answers

How often should a patient at risk for foot problems inspect their feet?

Daily, particularly between the toes Signup and view all the answers

What is a key requirement for airborne precautions to ensure effective transmission prevention?

Ensuring negative pressure in the room with multiple air exchanges Signup and view all the answers

What type of socks should individuals with diabetes or peripheral vascular disease wear daily?

Cotton socks to absorb sweat Signup and view all the answers

Which scenario correctly describes the use of droplet precautions?

A patient with the flu receiving visitors Signup and view all the answers

What is an essential item needed when following contact precautions?

Gowns and gloves for caregivers Signup and view all the answers

What is the primary function of protective precautions in a healthcare setting?

To safeguard immunocompromised patients from environmental pathogens Signup and view all the answers

Which precautionary measure is appropriate for a patient with a confirmed varicella infection?

Airborne precautions with visitor restrictions Signup and view all the answers

When donning personal protective equipment (PPE), what is the correct order to prevent contamination?

Mask, gown, gloves Signup and view all the answers

Which condition would require a negative pressure room as part of infection control measures?

Patient diagnosed with tuberculosis Signup and view all the answers

What is the recommended distance to maintain from a patient to minimize droplet transmission under droplet precautions?

At least 3 feet Signup and view all the answers

Under what condition should hand washing always be performed in patient care?

When a patient has diarrhea Signup and view all the answers

What is the recommended position for a patient at risk of aspiration during oral care?

Semi-Fowler's position Signup and view all the answers

Which method should be used to clean dentures?

Horizontal back-and-forth motion with a soft brush and denture cleaner Signup and view all the answers

What should be done with dentures when they are not in use?

Store in a denture cup with water to keep moist Signup and view all the answers

What is the key consideration for providing foot care to patients?

Preventing infection or pain that may interfere with gait Signup and view all the answers

What should be ready at the bedside of an unconscious patient during oral care?

Suction equipment Signup and view all the answers

Which of the following steps is part of denture care?

Remove dentures with gloved hands Signup and view all the answers

What technique should be used when brushing dentures?

Horizontal back-and-forth with a soft brush Signup and view all the answers

What is the minimum recommended duration for washing hands in patient care?

30 seconds Signup and view all the answers

What action should be taken before providing oral care to assess patient safety?

Check for aspiration risk and swallowing ability Signup and view all the answers

What is a crucial safety measure to implement for patients with sensory deficits?

Orient clients to room layout and keep personal items within reach Signup and view all the answers

Which approach should be avoided when communicating with a patient who has hearing loss?

Speaking in a loud voice to get attention Signup and view all the answers

What should a nurse do to effectively communicate with a patient experiencing aphasia?

Use picture charts as communication aids Signup and view all the answers

When caring for a patient with vision loss, which action is not recommended?

Touch the patient without explanation to avoid startling them Signup and view all the answers

In the context of caring for patients with disorientation, what is a necessary practice?

Post visible clocks and calendars for orientation Signup and view all the answers

Study Notes

Risk Factors for Infection

Inadequate hand hygiene can increase the risk of infection.
Patients with compromised health, such as:
- Recent surgery or indwelling devices
- Skin breakdown, wounds, or skin tears
- Poor oxygenation and impaired circulation
- Chronic or acute diseases (e.g., diabetes, renal failure, chronic lung disease)
Caregivers who do not follow medical asepsis or established hygiene standards can facilitate infection.
Factors like poor hygiene, nutrition, smoking, excessive alcohol consumption, and stress increase vulnerability.
Living in crowded environments heightens the risk of transmission.

Transmission Chain of Infection

Causative Agents: Include bacteria, viruses, fungi, prions, and parasites.
Reservoirs: Infection sources are humans, animals, food, organic matter on inanimate surfaces, water, soil, and insects.
Portal of Exit:
- Respiratory tract (e.g., Mycobacterium tuberculosis, Streptococcus pneumoniae)
- Gastrointestinal tract (e.g., Shigella, Salmonella)
- Skin/mucous membranes (e.g., HSV, varicella)
- Blood/body fluids (e.g., HIV, Hep B & C)
Mode of Transmission:
- Contact transmission: direct or indirect
- Fecal-oral transmission from improper hygiene
- Droplet transmission: during coughing, sneezing, or talking
- Airborne transmission: via droplets suspended in the air
- Vector-borne transmission through insects or animals.
Portal of Entry: The path by which the infection enters a new host, often the same as the portal of exit.
Susceptible Host: An individual with a compromised defense mechanism is more prone to infection.

Infection Prevention Strategies

Frequent and effective hand hygiene is crucial before and after patient care.
Educate patients on immunizations and the importance of maintaining good oral hygiene to reduce microbial growth.
Encourage adequate fluid intake to prevent urinary tract infections (UTIs) and skin breakdown.
For immobile patients, perform turning, coughing, deep breathing exercises, and use incentive spirometry every two hours.
Implement aseptic techniques and use personal protective equipment (PPE) like gloves, masks, gowns, and goggles.
Teach respiratory hygiene and coughing etiquette to minimize infection spread.

Infection Risk Assessment

Nurses should evaluate patients for infection risks related to their specific conditions, injuries, and environmental factors.

Transmission Precautions

Airborne Precautions: Protect against droplet infections smaller than 5 microns (e.g., measles, TB).
- Requires private rooms, N95 masks for caregivers, and negative pressure ventilation.
Droplet Precautions: Protect against larger droplets that can travel 3-6 feet (e.g., flu, pneumonia).
- Requires private or shared rooms with masking protocols.
Contact Precautions: Protect against infections requiring direct contact (e.g., respiratory viruses, scabies).
- Requires private rooms, gloves, gowns, and disposal of infectious materials.
Protective Precautions: Aimed at immunocompromised individuals, utilizing positive airflow and HEPA filtration.
- Requires a private room and specific air exchange measures.

Personal Protective Equipment (PPE)

Donning (putting on) and doffing (removing) PPE involves careful techniques to minimize contamination risks.

Risk Factors for Infection

Inadequate hand hygiene increases infection risk.
Patients with compromised health face higher infection likelihood, such as:
- Recent surgeries
- Presence of indwelling devices
- Skin breakdowns (wounds, tears)
- Poor oxygen levels
- Impaired circulation
- Chronic conditions like diabetes, renal failure, chronic lung disease.
Caregivers failing to adhere to aseptic standards contribute to infection risk.
Poor hygiene, nutrition, smoking, excessive alcohol, and stress in clients also elevate risk.
Crowded living environments further increase vulnerability to infections.

Transmission Chain of Infection

Causative Agent: Types include bacteria, viruses, fungi, prions, and parasites.
Reservoirs: Possible hosts are humans, animals, food, organic matter on surfaces, water, soil, and insects.
Portal of Exit: Routes through which pathogens leave a host include:
- Respiratory tract (e.g., Mycobacterium tuberculosis)
- Gastrointestinal tract (e.g., shigella, hepatitis A)
- Skin/mucous membranes (e.g., HSV, varicella)
- Blood/body fluids (e.g., HIV, Hepatitis B & C)
- Transplacental transmission is also a risk.
Modes of Transmission:
- Direct/indirect contact, fecal-oral routes, droplet and airborne transmission, and vector-borne transmission by insects.
Portal of Entry: Pathways into the host; often same as portals of exit.
Susceptible Host: Individuals with compromised defense mechanisms, such as skin breakdown, are more prone to infections.

Therapeutic Communication Techniques

Active Listening: Shows attentiveness to verbal and nonverbal cues.
Sharing Observations: Comments on patient's appearance or behavior.
Sharing Empathy: Understanding and accepting patient's feelings.
Sharing Hope: Encouragement and positivity enhance patient morale.
Sharing Humor: Strengthens relationships and promotes positive communication.
Sharing Feelings: Encourages expression of emotions, including negative feelings.
Using Touch: Comforting gestures are crucial for vulnerable patients.
Silence: Provides space for reflection and feeling management.
Providing Information: Important for informed decision-making and reducing anxiety.
Clarifying and Focusing: Ensures accurate understanding and concentrates on key points.
Paraphrasing: Summarizes messages in one’s own words for clarity.
Asking Relevant Questions: Opens dialogue for further information without overwhelming the patient.
Summarizing: Concisely reviews interaction for clarity and closure.
Self-Disclosure: Shares personal experiences to build trust.
Confrontation: Sensitively addresses inconsistencies in patient feelings or behaviors after establishing trust.

Hygiene in Patient Care

Hand Hygiene: Essential after patient contact, particularly with diarrhea.
Oral Care: Tailor care based on aspiration risks and monitor oral hygiene needs carefully.
Denture Care: Removes and stores dentures properly, cleaning them with appropriate techniques.
Foot Care: Prevents infections that could impair mobility; important for overall health.

Pain Management and Safety

Monitoring and administering: Pay attention to sedation levels and signs of respiratory depression with opioids.
Urinary and gastrointestinal management: Monitor intake/output and provide appropriate interventions for constipation and urinary retention.

Sensory Deficits

Causes: Include age-related changes, medical conditions, obstructions, or injury.
Communication Adaptation: Adjust communication styles based on specific sensory deficits (hearing, vision, disorientation).
Safety Precautions: Maintain a safe environment for patients with sensory impairments, keeping pathways clear and ensuring assistive devices are accessible.

Delegation Principles

Five Rights of Delegation:
- Right Task: Determining the appropriateness of the task for delegation.
- Right Circumstance: Assessing the conditions under which delegation is appropriate.
- Right Direction and Communication: Providing clear instructions and necessary information to UAP.
- Right Person: Selecting the most qualified individual for the task.
- Right Supervision: Planning follow-up to ensure tasks are completed correctly.

Delegable Tasks for Assistive Personnel

Vital signs monitoring for stable patients.
Assisting with feeding, grooming, bathing, and toileting.
Patient repositioning (turning).
Supporting patient ambulation.
Managing inventory of supplies.
Performing secretarial tasks.
Additional tasks may be delegated based on UAP capabilities and facility policies.

Hygiene and Patient Care

Bathing: Cleansing the body to improve circulation, promote relaxation, and support healing. Typically delegated to UAP, nurses remain responsible for data collection.
Hand Hygiene: Essential washing routines must be followed, especially after contact with diarrhea or using the restroom. Handwashing should last for 30 seconds.
Oral Care: Assess aspiration risk and prepare for possible emergencies. Gentle care required for patients with oral mucosa issues.
Denture Care: Proper removal and cleaning techniques are vital to prevent damage; dentures should be stored moist or reapplied immediately after cleaning.
Foot Care: Focus on preventing infections and providing comfort; document any related issues thoroughly.

Types of Pain

Acute Pain: Temporary and protective, often resolving with tissue healing. Characterized by noticeable physical responses such as tachycardia and anxiety. Requires treatment of the underlying cause; can develop into chronic pain if untreated.
Chronic Pain: Ongoing for over six months, it often does not require vital sign changes and may lead to depression or reduced functioning. Management focuses on relief and may include both cancer and non-cancer pain categories. Idiopathic pain lacks identifiable cause.
Pain Management Strategies:
- Nonpharmacological: Involves supportive techniques such as clean linens, proper positioning, cognitive-behavioral measures, and various therapies (e.g., acupuncture, distraction methods).
- Pharmacological: Consists of non-opioids, opioids, and adjuvants. Awareness of potential analgesic side effects is critical, especially with medications like acetaminophen.

Pain Assessment Tools

Numerical Rating Scale (NRS)
Visual Analog Scale (VAS)
Defense and Veterans Pain Rating Scale (DVPRS)
Adult Non-Verbal Pain Scale (NVPS)
Pain Assessment in Advanced Dementia Scale (PAINAD)
Behavioral Pain Scale (BPS)
Critical-Care Observation Tool (CPOT)

Sensory Complications

Differentiation between conductive and sensorineural hearing loss: Requires careful assessment of auditory function to determine appropriate interventions.

Older Adult Skin and Infection Indicators

Special attention to skin conditions and signs of infection is crucial in older adults. Proper assessment and documentation are essential for effective care intervention.

Safety Precautions for Patients

Patients, particularly those with peripheral neuropathy, should wear protective footwear and avoid open-toed shoes to prevent injury. Regular foot inspections are necessary to prevent undetected issues.

Risk Factors for Infection

Inadequate hand hygiene can lead to increased risk of infection.
Compromised health conditions include recent surgery, indwelling devices, skin breakdown, poor oxygenation, and impaired circulation.
Chronic diseases such as diabetes, renal failure, chronic lung disease, adrenal and hepatic insufficiency heighten susceptibility to infections.
Caregivers not adhering to proper medical asepsis standards contribute to infection risk.
Clients with poor hygiene, inadequate nutrition, smoking habits, excessive alcohol consumption, and high stress levels are more vulnerable.
Living in crowded environments increases the likelihood of infection transmission.

Transmission Chain of Infection

Causative agents include bacteria, viruses, fungi, prions, and parasites.
Reservoirs for infection can be humans, animals, food, organic matter, inanimate surfaces, water, soil, or insects.
Portals of exit from the host include:
- Respiratory tract: diseases like Mycobacterium tuberculosis and Streptococcus pneumoniae.
- Gastrointestinal tract: pathogens such as Shigella, Salmonella enteritidis, and Hepatitis A.
- Skin/mucous membranes: viruses like HSV and varicella.
- Blood/body fluids: HIV and Hepatitis B & C.
- Transplacental routes.
Modes of transmission:
- Direct contact (person-to-person) and indirect contact through objects.
- Fecal-oral transmission occurs when hand hygiene is inadequately performed.
- Droplet and airborne transmission during sneezing or coughing.
- Vector-borne transmission involves insects like ticks and mosquitoes.
Portals of entry to the host can align with portals of exit.
A susceptible host has a compromised defense mechanism (e.g., skin breakdown), increasing infection risk.

Patient Care Hygiene Practices

Hand hygiene: Always wash hands after contact with patients, especially those with diarrhea or after using the restroom. Wash for at least 30 seconds and sanitize upon entering or exiting patient rooms.
Oral care: Assess for aspiration risk and impaired swallowing. Employ gentle brushing for those with oral mucosa issues and keep suction equipment accessible for unconscious patients. Position patients on their side or semi-Fowler's.
Denture care: Remove and handle dentures carefully with gloved hands; clean using a soft brush with horizontal motion. Store dentures in a labeled cup, keeping them moist.
Foot care: Preventing infection or pain is vital for maintaining gait. Consider cultural beliefs during care. Daily hair brushing promotes scalp circulation; use appropriate tools to minimize injury. For limited mobility patients, utilize no-rinse shampoos.

Seizure Precautions

Ensure availability of rescue equipment (padding, oxygen, suction).
Maintain airway patency and provide rapid intervention.
Inspect the environment for safety; stay with the patient and call for help.
Lower the patient to the floor or bed to protect their head; do not restrain or place objects in the mouth during seizures.
After seizures, assess mental status, monitor oxygen saturation, and measure vital signs.

Pain Management

Nociceptive pain arises from tissue damage or inflammation; typically described as throbbing, aching, or localized and responds to opioids and non-opioid medications.
- Types include somatic (bones, joints, muscles), visceral (internal organs), and cutaneous (skin).
Neuropathic pain originates from damaged pain nerves and can include conditions like phantom limb pain and diabetic neuropathy. It is often described as intense, burning, or tingling, responding to adjuvant medications.

Opioid Management

Opioids are suitable for moderate to severe pain, especially in cancer patients. Monitor for sedation, respiratory depression, and orthostatic hypotension.
Handle urinary retention with interventions such as bethanechol and catheterization; manage nausea with antiemetics and encourage slow movements to reduce dizziness.
Monitor constipation through bowel sound assessment, fluid intake, and dietary modifications.

Sensory Deficits

Changes in sensory reception can occur gradually, reducing sensory input from the environment.
Contributing factors to vision loss include presbyopia, cataracts, glaucoma, diabetic retinopathy, and brain tumors.
Conductive hearing loss can arise from ear obstructions.

Transmission Precautions

Airborne Precautions: Protects against infections transmitted via droplets smaller than 5 mcg (e.g., measles, TB).
- Requires a private room, N95 masks for caregivers, and negative pressure rooms with 6-12 air exchanges/hour.
Droplet Precautions: For infections spread through droplets larger than 5 mcg, traveling 3-6 feet (e.g., influenza, pneumonia).
- Requires a private room or shared room with the same infection, masks for caregivers and visitors, and masks for infected patients outside their room.
Contact Precautions: Protects against direct and environmental contact infections (e.g., herpes, scabies, wound infections).
- Requires a private room or sharing with the same infection, gloves and gowns for caregivers, and proper disposal for infectious items.
Protective Precautions: Focuses on preventing infections in immunocompromised individuals.
- Requires a private room, positive airflow with 12 or more air exchanges/hour, HEPA filtration, and masks for patients when outside their room.

Personal Protective Equipment (PPE)

Donning (Putting On): Follow proper sequences to ensure maximum protection.
Doffing (Removal): Remove carefully to prevent contamination.

Patient Hygiene

Bathing Patients: Provide complete baths when possible; allow rest periods and perform partial baths for those who cannot tolerate complete bathing.
Giving a Bed Bath:
- Collect supplies, ensure privacy, explain procedures, and maintain hygiene throughout the process.

Oral Care

Essential for preventing pneumonia pathogens in long-term care residents.
Focus on meticulous hygiene for patients who are ill, injured, or unconscious.

Foot Care

Crucial for diabetes patients to prevent breakdown, pain, and infection.
Professionals should perform assessments and care: inspecting, cleaning, and moisturizing appropriately.

Nail Care

Assess nails for size, shape, condition, and any issues (e.g., fungus).
Care protocols differ for patients with diabetes; avoid soaking and cutting nails, favoring filing instead.

Hair Care

Support overall appearance and wellbeing; involves cleaning and management of ear and scalp health.

Caring for Patients with Sensory Deficits

General Communication: Use assistive devices if needed; maintain engagement to prevent isolation.
Hearing Loss: Speak clearly, face the patient, minimize background noise, and consider a sign language interpreter.
Vision Loss: Identify yourself, provide specific location information, and describe items before interaction.
Aphasia: Use clear language, pause for comprehension, and incorporate visual aids for better communication.
Disorientation: Approach calmly; maintain eye contact, use simple sentences, and provide orientation cues throughout care.

Safety Considerations

Keep pathways clear and call light accessible.
Ensure proper communication methods are used, understanding individual patient needs for effective interaction and safety.

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Description

Test your knowledge on the various risk factors associated with infection in patients. This quiz covers topics such as inadequate hand hygiene and individuals with compromised health. Understand how various conditions contribute to infection susceptibility.