NR_224_Final_Exam_Key_Concepts__FUNDS GRADED A
2/28/21
NOTE: Remember NR 224 requires you to answer exam questions in which you will have to not only
understand but also apply information related to the concepts covered in the course. The intent of this
study tool is to outline the major content that will be covered on the exam. Additional content may be
included on the exam.
Critical Thinking
Be prepared to prioritize and to consider the
best option when answering exam What are principles related to HIPAA?
questions. • Patients’ privacy, who the patient
give right to have his information
What considerations are important when • Patient information can be used or
determining the best option? disclosed by a health plan, provider
Whatever decision is best for the patient • HIPAA enables patients to find out
how their information may be used
When should the nurse delegate vs not and how it has been disclosed
• gives patients the right to examine
delegate?
and obtain a copy of their own health
Delegation: “transferring responsibility for a records and to request corrections.
performance of an activity or task while What is HIPAA?
retaining accountability for an outcome” • Health Insurance Portability and
Accountability Act
• assigning tasks to other healthcare • Focuses on Patient Health
professionals (vitals, labs); UAP Information
(unlicensed assistive personnel), • Stipulates how healthcare workers
LPNs can share information
A major component of the Health Insurance
Not delegate: “to do on your own or not Portability and Accountability Act (HIPAA),
share the tasks” the Privacy Rule, was introduced to promote
the use of standard methods of maintaining
• give meds, change in status, receive the privacy of protected health information
new meds, new admission, teaching (PHI) among health care agencies.
What are essential steps the nurse should do Nursing Process
prior to performing any skill on a patient? Review the steps in the nursing process. Be
-AIDET prepared to interpret a scenario/situation to
A-Acknowledge (greet the patient) determine the corresponding step in the
I- Introduce yourself nursing process.
D- duration of assessment • Assessment: gather all subjective
E- explain the procedure and objective data
T- thank you • Diagnosis: NANDA, nursing
diagnosis for actual problems,
-Hand hygiene and provide privacy
-Identify your patient using name and DOB Potential problems, or risk for
-Assess allergies problems.
-Assess pain
-Determine level of consciousness (LOC)
ACR/6.19.2020
,NR_224_Final_Exam_Key_Concepts__FUNDS GRADED A
• Outcome identification:
SMART goals for pt (patient) 1. During procedures that require
• Planning: nurse/pt make a plan to intentional perforation of the
achieve the goal patient’s skin, such as insertion of
• Implementation: how the nurse peripheral IV catheters or a
will put the plan into action & central intravenous line.
Interventions 2. when the integrity of the skin is
• Evaluation: was the goal met and broken as a result of trauma,
what needs to be adjusted
surgical incision, or burns
3. during procedures that involves
invasive procedures such as insertion
Consider nursing diagnoses that are
of a urinary catheter or surgical
applicable to a given situation/scenario.
instruments into sterile body cavities
such as insertion of a wound drain
List strategies/interventions that may
Infection Prevention and Control
prevent infection transmission.
What is the difference between clean
• Standard precaution (wash hands,
(aseptic) and sterile technique? gloves) => apply when contact with
blood, body fluid, non-intact skin,
• Clean is the routine hand hygiene, and mucous membrane.
drying and use of nonsterile gloves,
it uses for taking blood, examining • Hand hygiene is the most
patients, and feeding patients. effective basic technique in
preventing and controlling the
• Sterile techniques used for transmission of infection.
surgery and invasive procedures
with high rates of infection. It
involves What are principles associated with creating
surgical hand rub with long and maintaining a sterile field?
actin antiseptic, dry hands with consider the 2.5cm (1 inch) around the
sterile towel, sterile field (gown, sterile gloving contaminated
mask, gloves, supplies), skin must be waist level
prep, a dedicated room.
What is PPE?
• While clean means free from marks PPE: Personal protective equipment for
and stains, sterile goes even further protection against exposure to infectious
and is free from bacteria or materials. This includes gloves, mask,
goggles, hair net and gown.
microorganisms
Removal: gloves comes off first, then gown,
mask, head pieces, and first thing that goes
• Sterile: No SPORES or on
microorganisms
Standard precautions: handwashing
What are examples of skills and procedures What are the different types of isolation
that should be performed using clean precautions and considerations are
technique? Sterile technique? associated with each type?
ACR/6.19.2020
,NR_224_Final_Exam_Key_Concepts__FUNDS GRADED A
• Standard precautions should be in all settings and used Immunocompromise HEPA filter
it includes ha washing, when hands are visibly nd d
soiled used antibacterial soap and
water, when not visibly soiled use hand sanitizer or hand rub
and it must be 60% and above alcohol
• Airborne - smaller than 5 microns. What item should be removed first? Why?
Negative air pressure, 6-12 exchanges Remove gloves, eyewear, gown, then mask
using HEPA filter, N95 respirator, (top first then bottom), Removing = Gloves,
mask, eyewear, gown and mask.
private room. Measles, Tuberculosis
and Varicella (chicken pox)(MTV) Why? gloves could be visibly or non-visibly
soiled, so get rid of it first, then eye wear or
• droplets - larger than 5 microns.
private room or cohort, mask or goggles, gown to avoid the contaminants
respirator from spreading then mask
• contact - must have gloves and gown, Sterile field
private room or cohort patients.
● Sterile object remains sterile if
• PPE - positive air pressure, private
room, 12 and above air exchanges touched by another sterile object
using HEPA filter, mask worn by the ● Only objects that are sterile must be
patients
placed on a sterile field
● Sterile object is assumed contaminated if it is
Type Infection Barrier PPE out of field of vision or below the waist
Airborne Measles Private room with Mask ● A sterile object of field becomes contaminated
door closed
(small Varicella (chicken Negative pressure Respiratory
droplets) protection by prolonged exposure to air. It becomes
pox) airflow (6-12)
<5 microns TB
exchanges by
HEPA filter
device contaminated with in time
N95 worn
Air is not filtered ● Sterile surface come in contact with
inside room but by health
by HEPA care wet surface it becomes contaminated
workers by capillary action
gloves
Droplet Diphtheria Rubella Private
● Fluid flows in the direction of
Surgical
>5
Mumps
Streptococcal pharyngitis room or Mask gravity
microns Pneumonia cohort (within 3 ● The edges of a sterile field or
< 3 feet Influenza feet of
Meningitis container are considered
patient)
Hand contaminated
hygiene ○ (Think of the edges when
(after) opening the sterile gloves in
Respirator
lab)
Contact VRE (Vancomycin Private Gloves
Resistant Enterococci) room or Gown
MRSA
Vital Signs
C. Diff cohort What are the normal ranges associated with
Herpes simplex each vital sign?
Varicella zoster
Protective Allogeneic Private room Mask worn
hematopoietic stem Positive by patient
cell transplant airflow (>12)
ACR/6.19.2020
2/28/21
NOTE: Remember NR 224 requires you to answer exam questions in which you will have to not only
understand but also apply information related to the concepts covered in the course. The intent of this
study tool is to outline the major content that will be covered on the exam. Additional content may be
included on the exam.
Critical Thinking
Be prepared to prioritize and to consider the
best option when answering exam What are principles related to HIPAA?
questions. • Patients’ privacy, who the patient
give right to have his information
What considerations are important when • Patient information can be used or
determining the best option? disclosed by a health plan, provider
Whatever decision is best for the patient • HIPAA enables patients to find out
how their information may be used
When should the nurse delegate vs not and how it has been disclosed
• gives patients the right to examine
delegate?
and obtain a copy of their own health
Delegation: “transferring responsibility for a records and to request corrections.
performance of an activity or task while What is HIPAA?
retaining accountability for an outcome” • Health Insurance Portability and
Accountability Act
• assigning tasks to other healthcare • Focuses on Patient Health
professionals (vitals, labs); UAP Information
(unlicensed assistive personnel), • Stipulates how healthcare workers
LPNs can share information
A major component of the Health Insurance
Not delegate: “to do on your own or not Portability and Accountability Act (HIPAA),
share the tasks” the Privacy Rule, was introduced to promote
the use of standard methods of maintaining
• give meds, change in status, receive the privacy of protected health information
new meds, new admission, teaching (PHI) among health care agencies.
What are essential steps the nurse should do Nursing Process
prior to performing any skill on a patient? Review the steps in the nursing process. Be
-AIDET prepared to interpret a scenario/situation to
A-Acknowledge (greet the patient) determine the corresponding step in the
I- Introduce yourself nursing process.
D- duration of assessment • Assessment: gather all subjective
E- explain the procedure and objective data
T- thank you • Diagnosis: NANDA, nursing
diagnosis for actual problems,
-Hand hygiene and provide privacy
-Identify your patient using name and DOB Potential problems, or risk for
-Assess allergies problems.
-Assess pain
-Determine level of consciousness (LOC)
ACR/6.19.2020
,NR_224_Final_Exam_Key_Concepts__FUNDS GRADED A
• Outcome identification:
SMART goals for pt (patient) 1. During procedures that require
• Planning: nurse/pt make a plan to intentional perforation of the
achieve the goal patient’s skin, such as insertion of
• Implementation: how the nurse peripheral IV catheters or a
will put the plan into action & central intravenous line.
Interventions 2. when the integrity of the skin is
• Evaluation: was the goal met and broken as a result of trauma,
what needs to be adjusted
surgical incision, or burns
3. during procedures that involves
invasive procedures such as insertion
Consider nursing diagnoses that are
of a urinary catheter or surgical
applicable to a given situation/scenario.
instruments into sterile body cavities
such as insertion of a wound drain
List strategies/interventions that may
Infection Prevention and Control
prevent infection transmission.
What is the difference between clean
• Standard precaution (wash hands,
(aseptic) and sterile technique? gloves) => apply when contact with
blood, body fluid, non-intact skin,
• Clean is the routine hand hygiene, and mucous membrane.
drying and use of nonsterile gloves,
it uses for taking blood, examining • Hand hygiene is the most
patients, and feeding patients. effective basic technique in
preventing and controlling the
• Sterile techniques used for transmission of infection.
surgery and invasive procedures
with high rates of infection. It
involves What are principles associated with creating
surgical hand rub with long and maintaining a sterile field?
actin antiseptic, dry hands with consider the 2.5cm (1 inch) around the
sterile towel, sterile field (gown, sterile gloving contaminated
mask, gloves, supplies), skin must be waist level
prep, a dedicated room.
What is PPE?
• While clean means free from marks PPE: Personal protective equipment for
and stains, sterile goes even further protection against exposure to infectious
and is free from bacteria or materials. This includes gloves, mask,
goggles, hair net and gown.
microorganisms
Removal: gloves comes off first, then gown,
mask, head pieces, and first thing that goes
• Sterile: No SPORES or on
microorganisms
Standard precautions: handwashing
What are examples of skills and procedures What are the different types of isolation
that should be performed using clean precautions and considerations are
technique? Sterile technique? associated with each type?
ACR/6.19.2020
,NR_224_Final_Exam_Key_Concepts__FUNDS GRADED A
• Standard precautions should be in all settings and used Immunocompromise HEPA filter
it includes ha washing, when hands are visibly nd d
soiled used antibacterial soap and
water, when not visibly soiled use hand sanitizer or hand rub
and it must be 60% and above alcohol
• Airborne - smaller than 5 microns. What item should be removed first? Why?
Negative air pressure, 6-12 exchanges Remove gloves, eyewear, gown, then mask
using HEPA filter, N95 respirator, (top first then bottom), Removing = Gloves,
mask, eyewear, gown and mask.
private room. Measles, Tuberculosis
and Varicella (chicken pox)(MTV) Why? gloves could be visibly or non-visibly
soiled, so get rid of it first, then eye wear or
• droplets - larger than 5 microns.
private room or cohort, mask or goggles, gown to avoid the contaminants
respirator from spreading then mask
• contact - must have gloves and gown, Sterile field
private room or cohort patients.
● Sterile object remains sterile if
• PPE - positive air pressure, private
room, 12 and above air exchanges touched by another sterile object
using HEPA filter, mask worn by the ● Only objects that are sterile must be
patients
placed on a sterile field
● Sterile object is assumed contaminated if it is
Type Infection Barrier PPE out of field of vision or below the waist
Airborne Measles Private room with Mask ● A sterile object of field becomes contaminated
door closed
(small Varicella (chicken Negative pressure Respiratory
droplets) protection by prolonged exposure to air. It becomes
pox) airflow (6-12)
<5 microns TB
exchanges by
HEPA filter
device contaminated with in time
N95 worn
Air is not filtered ● Sterile surface come in contact with
inside room but by health
by HEPA care wet surface it becomes contaminated
workers by capillary action
gloves
Droplet Diphtheria Rubella Private
● Fluid flows in the direction of
Surgical
>5
Mumps
Streptococcal pharyngitis room or Mask gravity
microns Pneumonia cohort (within 3 ● The edges of a sterile field or
< 3 feet Influenza feet of
Meningitis container are considered
patient)
Hand contaminated
hygiene ○ (Think of the edges when
(after) opening the sterile gloves in
Respirator
lab)
Contact VRE (Vancomycin Private Gloves
Resistant Enterococci) room or Gown
MRSA
Vital Signs
C. Diff cohort What are the normal ranges associated with
Herpes simplex each vital sign?
Varicella zoster
Protective Allogeneic Private room Mask worn
hematopoietic stem Positive by patient
cell transplant airflow (>12)
ACR/6.19.2020
