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Questions and Answers
What is a recommended prevention method for atelectasis in the post-operative phase?
What is a recommended prevention method for atelectasis in the post-operative phase?
What should be done to prevent ventilator-associated pneumonia?
What should be done to prevent ventilator-associated pneumonia?
Which of the following is a prevention strategy for a surgical site infection after four post-operative days?
Which of the following is a prevention strategy for a surgical site infection after four post-operative days?
What is an effective prevention method for DVT/PE in post-operative patients?
What is an effective prevention method for DVT/PE in post-operative patients?
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What is included in the care of catheter-associated UTIs during post-operative days 3-5?
What is included in the care of catheter-associated UTIs during post-operative days 3-5?
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What is the appropriate action for a Stage I pressure ulcer?
What is the appropriate action for a Stage I pressure ulcer?
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What condition must be avoided when delegating patient care?
What condition must be avoided when delegating patient care?
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Which stage of pressure ulcer is characterized by full thickness damage involving adipose tissue?
Which stage of pressure ulcer is characterized by full thickness damage involving adipose tissue?
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What is the maximum time a hydrocolloid dressing should typically remain on a Stage II pressure ulcer?
What is the maximum time a hydrocolloid dressing should typically remain on a Stage II pressure ulcer?
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Which scoring range indicates a 'Moderate Risk' on the Braden Scale?
Which scoring range indicates a 'Moderate Risk' on the Braden Scale?
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How often should a patient be turned to prevent pressure ulcers?
How often should a patient be turned to prevent pressure ulcers?
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What type of tissue can be seen in a Stage IV pressure ulcer?
What type of tissue can be seen in a Stage IV pressure ulcer?
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Which of the following is NOT a consideration for performing a risk assessment using the Braden Scale?
Which of the following is NOT a consideration for performing a risk assessment using the Braden Scale?
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What does a total score of 12 or less indicate on the Braden scale?
What does a total score of 12 or less indicate on the Braden scale?
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What is the correct method for cleaning intact skin?
What is the correct method for cleaning intact skin?
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Which of the following is NOT included in the Morse Fall Risk Assessment?
Which of the following is NOT included in the Morse Fall Risk Assessment?
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What should be the priority action to prevent the spread of infection?
What should be the priority action to prevent the spread of infection?
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What type of precautions should be used for C. diff infections?
What type of precautions should be used for C. diff infections?
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For what condition is epinephrine often used as a major treatment?
For what condition is epinephrine often used as a major treatment?
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Which disease is primarily prevented by vaccination with the MMR vaccine?
Which disease is primarily prevented by vaccination with the MMR vaccine?
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What is the first step in removing personal protective equipment (PPE)?
What is the first step in removing personal protective equipment (PPE)?
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Which infection is associated with symptoms of severe and foul-smelling diarrhea?
Which infection is associated with symptoms of severe and foul-smelling diarrhea?
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What should be avoided when flushing wounds?
What should be avoided when flushing wounds?
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What is the transmission route for Yersinia pestis?
What is the transmission route for Yersinia pestis?
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Which of the following is considered a primary prevention measure?
Which of the following is considered a primary prevention measure?
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What is the recommended method for transporting patients with contact infections?
What is the recommended method for transporting patients with contact infections?
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Which condition is characterized by a bullseye rash?
Which condition is characterized by a bullseye rash?
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What is a common prevention strategy for atelectasis and pneumonia during the first two post-operative days?
What is a common prevention strategy for atelectasis and pneumonia during the first two post-operative days?
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Which of the following practices is recommended to prevent catheter-associated urinary tract infections (CAUTIs) during post-operative days three to five?
Which of the following practices is recommended to prevent catheter-associated urinary tract infections (CAUTIs) during post-operative days three to five?
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What is the best prevention method for a surgical site infection beyond four post-operative days?
What is the best prevention method for a surgical site infection beyond four post-operative days?
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What action can help prevent deep vein thrombosis (DVT) in post-operative patients?
What action can help prevent deep vein thrombosis (DVT) in post-operative patients?
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Which nursing action is important for preventing ventilator-associated pneumonia in post-operative patients?
Which nursing action is important for preventing ventilator-associated pneumonia in post-operative patients?
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What is the primary goal when delegating care for a stable patient?
What is the primary goal when delegating care for a stable patient?
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What is a characteristic feature of a Stage I pressure ulcer?
What is a characteristic feature of a Stage I pressure ulcer?
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Which dressing is recommended for managing a Stage III pressure ulcer?
Which dressing is recommended for managing a Stage III pressure ulcer?
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What is a critical nursing intervention to prevent pressure ulcers?
What is a critical nursing intervention to prevent pressure ulcers?
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What does an unstageable pressure ulcer mean?
What does an unstageable pressure ulcer mean?
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Which of the following should not be done when caring for pressure ulcers?
Which of the following should not be done when caring for pressure ulcers?
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What is a key feature of a hydrocolloid dressing used in wound care?
What is a key feature of a hydrocolloid dressing used in wound care?
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What does the Braden Scale assess in patients at risk for pressure ulcers?
What does the Braden Scale assess in patients at risk for pressure ulcers?
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What does a total score of 10–12 on the Braden Scale indicate?
What does a total score of 10–12 on the Braden Scale indicate?
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Which of the following cleaning methods is appropriate for broken skin at risk for infection?
Which of the following cleaning methods is appropriate for broken skin at risk for infection?
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What is the primary method for preventing the spread of infections?
What is the primary method for preventing the spread of infections?
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What type of precautions should be taken for a patient with a confirmed case of C. diff?
What type of precautions should be taken for a patient with a confirmed case of C. diff?
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What potential impact can frequent rounds and bed/chair alarms have in a clinical setting?
What potential impact can frequent rounds and bed/chair alarms have in a clinical setting?
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Which of the following infections requires a n95 mask or surgical mask during precautions?
Which of the following infections requires a n95 mask or surgical mask during precautions?
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When should soap and water be used over hand sanitizers?
When should soap and water be used over hand sanitizers?
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What is a common cause of the infection known as Impetigo?
What is a common cause of the infection known as Impetigo?
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What should be done for a patient with a confirmed respiratory syncytial virus (RSV) infection?
What should be done for a patient with a confirmed respiratory syncytial virus (RSV) infection?
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Which disease can be caused by the ingestion of undercooked food?
Which disease can be caused by the ingestion of undercooked food?
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Which of the following is categorized under tertiary prevention?
Which of the following is categorized under tertiary prevention?
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What is the recommended action before transporting a patient with contact infection?
What is the recommended action before transporting a patient with contact infection?
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In which infection should a patient be cohort with others who have the same infection?
In which infection should a patient be cohort with others who have the same infection?
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What is true regarding the removal of personal protective equipment (PPE)?
What is true regarding the removal of personal protective equipment (PPE)?
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Study Notes
Delegation
- Delegate stable patients with uncomplicated procedures and common, stable diseases.
- Avoid delegating patients with ABC issues (airway, breathing, circulation) or those who are postoperative day 1 or less.
- Lower licenses cannot assess admissions or teach.
- Lower licenses can educate discharges.
Safety and Infection
Pressure Ulcers (Decubitus)
- Stage I: Non-blanchable redness (erythema), superficial, intact skin.
- Stage II: Red or pink ulcer, partial thickness (epidermis and dermis damage), risk of infection. Use hydrocolloid dressing for autolytic debridement.
- Stage III: Yellowish ulcer, full thickness (epidermis, dermis, deeper tissues damage). Use wet-to-dry dressing until granular tissue. Consult wound care, debridement needed.
- Stage IV: Bone or muscle showing, full thickness. Use wet-to-dry dressing until granular tissue. Consult wound care, debridement needed.
- Unstageable: Black, unable to assess underlying tissues, wound obscured by slough or eschar. Wet-to-dry dressing initially.
- Nx Tip: Wet-to-dry dressing: gauze moistened, placed, covered. Mechanical debridement occurs on removal. Basic method, can be uncomfortable .Wound care teams manage acute & chronic wounds.
Prophylaxis for Pressure Ulcers
- Basic Care and Comfort: Turn patient every 2 hours. Do NOT massage bony prominences. Use specialty rotation beds for stages III & IV. Range-of-motion exercises. Use heel cushions to offload. Use and monitor the Braden Scale.
Taking Care of Skin
- Intact Skin: Soap and water.
- Broken/Infected Skin: Alcohol, diluted hydrogen peroxide, chlorhexidine, neomycin, Betadine (surgical only), normal saline for flushing (avoid cytotoxic agents).
Falls
- Prophylaxis for Falls: Frequent rounding, rooms close to nurses' station, bed/chair alarms.
- Morse Fall Risk Assessment (Variables): History of falls, secondary diagnosis, ambulatory aid, IV therapy/heparin lock, gait, mental status.
Infections
- Horizontal Transmission: Person-to-person.
- Vertical Transmission: Mother-to-child.
- Priority: Wash hands!
- Standard/Universal Precautions: Wear gloves. Bloodborne infections: Ebola, Hep B, Hep C, HIV, Anthrax (inhaled powder, non-communicable).
- Contact Precautions: Wear gloves and gown. C. Diff, VRE/MRSA (including infected open wounds), gastroenteritis (viral, rotavirus, norovirus).
- Droplet Precautions: Wear gloves, gown, mask, goggles. Epiglottitis, influenza, mumps, rubella, streptococcus, pharyngitis, pneumonia.
- Airborne Precautions: Wear N95 or surgical mask, negative airflow room. Herpes zoster, measles, varicella, SARS, tuberculosis.
- Other Infection Routes: Yersinia pestis (bubonic plague), Shigella (diarrhea), yellow fever (mosquitoes, headache, vomiting), West Nile virus(mosquitoes, meningitis), Lyme disease(ticks, bullseye rash, flu-like), brucellosis (uncooked meat, milk), typhoid fever (contaminated food/water, diarrhea), pinworm (ingestion, fecal-oral route), Legionnaires’ disease (inhaling droplets).
- Cohorting of Patients: Do not cohort airborne patients, immunosuppressed or immunocompromised patients, patients with actual infections (anything ending in "itis"). Cohort similar infections. "4-foot rule"
Transporting of Patients
- Contact Infection: Wear gown.
- Droplet or Airborne Infection: Wear mask.
Neutropenic Precautions
- Suppressed immune systems (AIDS, major burns, lupus).
- Do not cohort with other patients.
- No fresh fruit, vegetables, flowers, pets, or children.
Open Wounds
- Cover the wound. Follow contact precautions.
Removing PPE
- Remove gloves first. Gloves → Goggles → Gown → Mask → Wash hands.
Preventions (Types)
- Primary Prevention: Prevent a problem from occurring (vaccinations, condoms, exercise, diet).
- Secondary Prevention: Screenings (mammograms, colonoscopies, PSA, pap smears).
- Tertiary Prevention: Prevent progression (post-heart attack aspirin regimen).
Post-Op Fever (5 W's)
- Wind: Atelectasis/pneumonia (deep breathing, incentive spirometry, splint chest, pain management, ventilator-associated pneumonia, elevate head, frequent oral care, PPI).
- Water: UTI/CAUTI (switch catheter every 72 hours, perineal care, push fluids).
- Wound: Surgical site infection (surgical staff does first dressing, nursing changes after 24 hours, sterile technique, cleaning agents).
- Walking: DVT/PE (early ambulation, sequential compression devices, TED stockings, subQ heparin/enoxaparin).
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Description
This quiz covers critical aspects of nursing delegation practices, focusing on stable patients and infection control. Additionally, it addresses the stages of pressure ulcers and appropriate care measures. Test your knowledge on these essential nursing concepts.
