NR 224 EXAM 1,2 AND 3 ACTUAL EXAM (COMPLETE COURSE)
QUESTIONS AND CORRECT DETAILED ANSWERS
Who is at increased risk of infection? - ANSWER: -elderly
-infants
-immobility
-autoimmune
-malnourished
-immunocompromised
-transplant
-chemo
-HIV
-steroids
Body's Natural Defenses - ANSWER: -skin
-mucus membranes
-saliva/tears/sweat
-inflammation
-GI/GU (flushing)
-immune system
-respiratory tract (cilia/cough)
What is the nurses role in infection control? - ANSWER: assess, education, use
proper precautions
Chain of Infection - ANSWER: 1. Infectious Agent
2. Reservoir
3. Portal of Exit
4. Mode of Transmission
5.Portal of Entry
6. Susceptible Host
*goal is to break the chain
Infectious Agent - ANSWER: -bacteria, virus, protozoa, fungus
-resident flora: bacteria that is already present
-transient flora: attaches to the skin -> causes infection
-virulence: strength
Reservoir - ANSWER: -H2O, body fluids, animals, insects, food, people
-needs proper environment (temp, pH, light, O2)
Portal of Exit - ANSWER: -body fluids, respiratory tract, GI, GU, mucus membranes,
skin, blood, transplacental
,Mode of Transmission - ANSWER: -direct contact: fecal-oral, shaking hands (contact
precautions
-indirect contact: objects, needles (contact precautions)
-droplet: 3ft travel, bigger (droplet precautions)
-airborne: smaller, evaporated droplets (airborne precautions)
Tier 1 - ANSWER: standard precautions: hand-washing, gloves, needle safety,
proper disposal of biohazard
Tier 2 - ANSWER: contact: gown and gloves (MRSA, VRE)
modified contact: soap, water, bleach based products (CDIFF)
droplet: mask, gloves, gown (flu, pneumonia)
airborne: negative air flow, hepa filter, antiroom, N95 mask, gown, gloves (TB,
measles, varicella, meningitis)
Port of Entry - ANSWER: -preferably same as exit
Susceptible Host - ANSWER: -ability to get infection, vaccinations make host lest
susceptible
Surgical Asepsis - ANSWER: -hands above waist (even when throwing away trash)
-eliminate all pathogens
-some dressing changes
-catheterizations
-surgical procedures
-not needed for NG tube insertions since the cavity is not sterile
-dont put things on bedside table!
Nursing responsibilities with skin - ANSWER: -assessment
-prevention of skin breakdown (reassess every-time you get pt.)
-important since when a pressure ulcer happens - WE pay for it, not
medicare/medicaid
High risk for skin breakdown - ANSWER: -elderly, obesity, neuro issues, same as list
for increased risk for infection
Braden Scale - ANSWER: checks for risk of skin breakdown, the more points, the
less likely for skin breakdown, 12 or less = high risk
Pressure Ulcers - ANSWER: -capillary displacement -> lack of blood flow = lack of O2
-> ischemia -> necrosis
Factors for Pressure Ulcers - ANSWER: -intensity: intense pressure or light pressure
over a long time
-duration
-tolerance: how strong is skin, health, malnourished?
, Stage I Pressure Ulcer - ANSWER: -non-blanchable erythema
Stage II Pressure Ulcer - ANSWER: -partial thickness loss of dermis
-shallow open ulcer with red pink wound bed
-open or intact blister
Stage III Pressure Ulcer - ANSWER: -full thickness skin loss
-subcutaneous fat may be visible
-tunneling or undermining
Stage IV Pressure Ulcer - ANSWER: -full thickness tissue loss
-visible muscle, bone, tendon
-undermining
Describing a Wound - ANSWER: -measure
-look at wound bed itself
-describe (yellow)
-tunneling/undermining (describe like a clock, cm)
-drainage (purulent, serous, serosanguinous (pink tinge), sanguinous (bleeding)),
amount of drainage (scant, small, moderate, excessive amount)
-odor
Skin Shear - ANSWER: -friction (a force that occurs in a direction to oppose
movement), force exerted against the skin while the skin remains stationary
Skin Tear - ANSWER: tear in skin from something
Prevention of Skin Breakdown - ANSWER: -nutrition, change brief consistently
(acidity), barrier cream
Types of Wound Healing - ANSWER: primary intention
secondary intention
tertiary intention
Primary intention wound healing - ANSWER: sutures, edges together
secondary intention wound healing - ANSWER: any other wound, leaves a scar
Tertiary intention wound healing - ANSWER: leave someone open to look for signs of
infection
granulation tissue - ANSWER: healthy tissue
wound healing complications - ANSWER: hemorrhage, infection, dehiscence,
evisceration
QUESTIONS AND CORRECT DETAILED ANSWERS
Who is at increased risk of infection? - ANSWER: -elderly
-infants
-immobility
-autoimmune
-malnourished
-immunocompromised
-transplant
-chemo
-HIV
-steroids
Body's Natural Defenses - ANSWER: -skin
-mucus membranes
-saliva/tears/sweat
-inflammation
-GI/GU (flushing)
-immune system
-respiratory tract (cilia/cough)
What is the nurses role in infection control? - ANSWER: assess, education, use
proper precautions
Chain of Infection - ANSWER: 1. Infectious Agent
2. Reservoir
3. Portal of Exit
4. Mode of Transmission
5.Portal of Entry
6. Susceptible Host
*goal is to break the chain
Infectious Agent - ANSWER: -bacteria, virus, protozoa, fungus
-resident flora: bacteria that is already present
-transient flora: attaches to the skin -> causes infection
-virulence: strength
Reservoir - ANSWER: -H2O, body fluids, animals, insects, food, people
-needs proper environment (temp, pH, light, O2)
Portal of Exit - ANSWER: -body fluids, respiratory tract, GI, GU, mucus membranes,
skin, blood, transplacental
,Mode of Transmission - ANSWER: -direct contact: fecal-oral, shaking hands (contact
precautions
-indirect contact: objects, needles (contact precautions)
-droplet: 3ft travel, bigger (droplet precautions)
-airborne: smaller, evaporated droplets (airborne precautions)
Tier 1 - ANSWER: standard precautions: hand-washing, gloves, needle safety,
proper disposal of biohazard
Tier 2 - ANSWER: contact: gown and gloves (MRSA, VRE)
modified contact: soap, water, bleach based products (CDIFF)
droplet: mask, gloves, gown (flu, pneumonia)
airborne: negative air flow, hepa filter, antiroom, N95 mask, gown, gloves (TB,
measles, varicella, meningitis)
Port of Entry - ANSWER: -preferably same as exit
Susceptible Host - ANSWER: -ability to get infection, vaccinations make host lest
susceptible
Surgical Asepsis - ANSWER: -hands above waist (even when throwing away trash)
-eliminate all pathogens
-some dressing changes
-catheterizations
-surgical procedures
-not needed for NG tube insertions since the cavity is not sterile
-dont put things on bedside table!
Nursing responsibilities with skin - ANSWER: -assessment
-prevention of skin breakdown (reassess every-time you get pt.)
-important since when a pressure ulcer happens - WE pay for it, not
medicare/medicaid
High risk for skin breakdown - ANSWER: -elderly, obesity, neuro issues, same as list
for increased risk for infection
Braden Scale - ANSWER: checks for risk of skin breakdown, the more points, the
less likely for skin breakdown, 12 or less = high risk
Pressure Ulcers - ANSWER: -capillary displacement -> lack of blood flow = lack of O2
-> ischemia -> necrosis
Factors for Pressure Ulcers - ANSWER: -intensity: intense pressure or light pressure
over a long time
-duration
-tolerance: how strong is skin, health, malnourished?
, Stage I Pressure Ulcer - ANSWER: -non-blanchable erythema
Stage II Pressure Ulcer - ANSWER: -partial thickness loss of dermis
-shallow open ulcer with red pink wound bed
-open or intact blister
Stage III Pressure Ulcer - ANSWER: -full thickness skin loss
-subcutaneous fat may be visible
-tunneling or undermining
Stage IV Pressure Ulcer - ANSWER: -full thickness tissue loss
-visible muscle, bone, tendon
-undermining
Describing a Wound - ANSWER: -measure
-look at wound bed itself
-describe (yellow)
-tunneling/undermining (describe like a clock, cm)
-drainage (purulent, serous, serosanguinous (pink tinge), sanguinous (bleeding)),
amount of drainage (scant, small, moderate, excessive amount)
-odor
Skin Shear - ANSWER: -friction (a force that occurs in a direction to oppose
movement), force exerted against the skin while the skin remains stationary
Skin Tear - ANSWER: tear in skin from something
Prevention of Skin Breakdown - ANSWER: -nutrition, change brief consistently
(acidity), barrier cream
Types of Wound Healing - ANSWER: primary intention
secondary intention
tertiary intention
Primary intention wound healing - ANSWER: sutures, edges together
secondary intention wound healing - ANSWER: any other wound, leaves a scar
Tertiary intention wound healing - ANSWER: leave someone open to look for signs of
infection
granulation tissue - ANSWER: healthy tissue
wound healing complications - ANSWER: hemorrhage, infection, dehiscence,
evisceration
