NRSG 200 EXAM 1 UPDATED ACTUAL Questions and
CORRECT Answers
Discuss the differences between medical and surgical Medical Asepsis--> "clean technique" eliminates MOST pathogenic
asepsis. microorganisms (reduce # and spread of microbes)
ex) administering oral meds, personal hygiene
Surgical Asepsis-->"sterile technique" eliminates ALL microorganisms
ex) sterile dressing changes, inserting urinary catheter
Identify the signs/symptoms of inflammation. Signs (objective) & Symptoms(subjective) Pain, Redness, Swelling, Heat, Impaired
Function
Identify nursing diagnosis and interventions for clients at Nursing Diagnosis--> Susceptible to invasion and multiplication of pathogenic
risk for an infection microorganisms
Interventions--> Immunizations, Proper hand hygiene, Aseptic technique of all IV
lines, Appropriate wound care technique, Teach family members how to avoid
infections
Identify nursing diagnosis and interventions for clients w/ Nursing Diagnosis-->Shows apparent signs and symptoms of infectious disease
Active infection (Fever, fatigue, Headache, Sneezing, Sore Throat, Diarrhea)
Interventions Maintain or restore defenses (eating healthy, sleeping, activity),
Avoid spread of infectious organisms, Reduce or alleviate associated problems
Identify clients with the highest risk for infection. o Economically disadvantaged
o Individuals exposed to disease outbreak
o Individuals exposed to increased environmental pathogens
o Low level of education
o Older age
, Discuss the practice of and rationale for standard Hand Hygiene--> SINGLE MOST IMPORTANT MEASURE TO REDUCE SPREAD OF
precautions MICROORGANISMS
Gloves--> when touching blood or other body fluids, open skin, mucous
membranes or preforming non invasive procedures
Gown-->When soiling of clothes is likely, assessing or changing wound dressing
Mask, Eye Protection & Face Shield--> when splashing of body fluids are likely
Rationale: To protect healthcare providers from infection and prevent the spread
of infection from patient to patient
Demonstrate proper procedures for hand hygiene. o Use warm water & Scrub hands for at least 20 seconds (make sure to get front,
back, sides, between fingers and under nails)
o Use alcohol based waterless product when hands are not visibly soiled
o Always use anti-bacterial soap and water for C.diff
o Before and after interacting with patient
o After touching with bare hands instruments, equipment, materials, and other
objects that are likely to be contaminated
Describe the appropriate personal protective equipment Contact--> Gloves and Gown
necessary for contact, airborne, and droplet precautions. Airborne--> N-95 respirator , Negative pressure (AIIR) room
Droplet--> Surgical maks
Discuss factors affecting an individual's ability to protect o Age & Development
themselves from injury. o Lifestyle
o Mobility & health status-->inhibit ability to take care of self
o Sensory-perceptual alterations
o Cognitive awareness-->developmental delays & dementia
o Emotional state--> are they able to engage??
o Ability to communicate
o Safety Awareness
Identify nursing diagnoses related to safety issues. Risk for Aspiration
Risk for Injury
Risk for Falls
Impaired Home Maintenance
What are the nursing interventions for Risk for Monitor level of consciousness, cough reflex, gag reflex, and swallowing ability;
Aspiration? Check nasogastric or gastrostomy before feeding
What are the nursing interventions for Risk for Injury? Monitor environmental risk factors/Develop effective risk control
strategies/Follows selected risk control strategies
What are the nursing interventions for Risk for Falls? Fall prevention behavior: Use assistive devices correctly/Eliminate clutter, spills,
glare from floor/Uses safe transfer procedures
What are the nursing interventions for Impaired home Involve client (& family) in deciding home maintenance requirements; Provide info
maintenance? on how to make environment safe and clean; Help family use social support
network
CORRECT Answers
Discuss the differences between medical and surgical Medical Asepsis--> "clean technique" eliminates MOST pathogenic
asepsis. microorganisms (reduce # and spread of microbes)
ex) administering oral meds, personal hygiene
Surgical Asepsis-->"sterile technique" eliminates ALL microorganisms
ex) sterile dressing changes, inserting urinary catheter
Identify the signs/symptoms of inflammation. Signs (objective) & Symptoms(subjective) Pain, Redness, Swelling, Heat, Impaired
Function
Identify nursing diagnosis and interventions for clients at Nursing Diagnosis--> Susceptible to invasion and multiplication of pathogenic
risk for an infection microorganisms
Interventions--> Immunizations, Proper hand hygiene, Aseptic technique of all IV
lines, Appropriate wound care technique, Teach family members how to avoid
infections
Identify nursing diagnosis and interventions for clients w/ Nursing Diagnosis-->Shows apparent signs and symptoms of infectious disease
Active infection (Fever, fatigue, Headache, Sneezing, Sore Throat, Diarrhea)
Interventions Maintain or restore defenses (eating healthy, sleeping, activity),
Avoid spread of infectious organisms, Reduce or alleviate associated problems
Identify clients with the highest risk for infection. o Economically disadvantaged
o Individuals exposed to disease outbreak
o Individuals exposed to increased environmental pathogens
o Low level of education
o Older age
, Discuss the practice of and rationale for standard Hand Hygiene--> SINGLE MOST IMPORTANT MEASURE TO REDUCE SPREAD OF
precautions MICROORGANISMS
Gloves--> when touching blood or other body fluids, open skin, mucous
membranes or preforming non invasive procedures
Gown-->When soiling of clothes is likely, assessing or changing wound dressing
Mask, Eye Protection & Face Shield--> when splashing of body fluids are likely
Rationale: To protect healthcare providers from infection and prevent the spread
of infection from patient to patient
Demonstrate proper procedures for hand hygiene. o Use warm water & Scrub hands for at least 20 seconds (make sure to get front,
back, sides, between fingers and under nails)
o Use alcohol based waterless product when hands are not visibly soiled
o Always use anti-bacterial soap and water for C.diff
o Before and after interacting with patient
o After touching with bare hands instruments, equipment, materials, and other
objects that are likely to be contaminated
Describe the appropriate personal protective equipment Contact--> Gloves and Gown
necessary for contact, airborne, and droplet precautions. Airborne--> N-95 respirator , Negative pressure (AIIR) room
Droplet--> Surgical maks
Discuss factors affecting an individual's ability to protect o Age & Development
themselves from injury. o Lifestyle
o Mobility & health status-->inhibit ability to take care of self
o Sensory-perceptual alterations
o Cognitive awareness-->developmental delays & dementia
o Emotional state--> are they able to engage??
o Ability to communicate
o Safety Awareness
Identify nursing diagnoses related to safety issues. Risk for Aspiration
Risk for Injury
Risk for Falls
Impaired Home Maintenance
What are the nursing interventions for Risk for Monitor level of consciousness, cough reflex, gag reflex, and swallowing ability;
Aspiration? Check nasogastric or gastrostomy before feeding
What are the nursing interventions for Risk for Injury? Monitor environmental risk factors/Develop effective risk control
strategies/Follows selected risk control strategies
What are the nursing interventions for Risk for Falls? Fall prevention behavior: Use assistive devices correctly/Eliminate clutter, spills,
glare from floor/Uses safe transfer procedures
What are the nursing interventions for Impaired home Involve client (& family) in deciding home maintenance requirements; Provide info
maintenance? on how to make environment safe and clean; Help family use social support
network
