NUR 2090 FINAL EXAM Questions &
Answers(GRADED A)
Indications for washing hands with soap and water - ANSWER Visibly dirty hands,
hands visibly soiled with body fluids; after using the toilet
Indications for alcohol-based hand sanitizer - ANSWER If hands are not visibly soiled,
before and after touching a pt, before handling an invasive device for pt care, after
contact with body fluids or secretions, mucous membranes, non intact skin, or wound
dressings, between contact with inanimate surfaces and objects and after removing
sterile or nonsterile gloves
Medical Asepsis - ANSWER "Clean technique"
- Used for procedures involving intact skin, non sterile body cavities (surfaces of the
mouth, GI tract, reproductive tract), and infected wounds
- Includes procedures such as infected or chronic wound care, nasopharyngeal
swabbing, routine gynecological exams
Surgical Asepsis - ANSWER "Sterile technique"
*To be sterile, an object must be free from all microorganisms*
- Used to prevent the introduction or spread of pathogens from the environment into the
patient
- Used for procedures involving entry into sterile body cavities, organs vascular spaces
or across mucous membranes
(Insertion of IV catheters, injections, urinary catheterization, some irrigation of drainage
tubes, all operative procedures)
Chain of Infection - ANSWER infectious agent, reservoir, portal of exit, mode of
transmission, portal of entry, susceptible host
Progress of Infection (Periods) - ANSWER Incubation period
Prodromal period
Acute phase
Convalescent period
Contact Precautions - ANSWER private room, clean gloves, gown
multidrug resistant organisms; infectious diarhhea (C.Diff, shigella, Norovirus);
infectious skin conditions (impetigo, herpes, S.aureus)
Vehicle Precautions - ANSWER involves the transfer of pathogens by way of vehicles or
contaminated items
,(food can carry Salmonella, water can carry Legionella, drugs can carry bacteria from
contaminated infusion supplies, non sterile surgical instruments can carry pathogens
into surgical incisions, and blood can carry hepatitis and HIV)
droplet precautions - ANSWER private room or cohab, mask within 3 feet, masks for
providers and visitors
transmission of large droplets through sneezing, coughing, or talking: influenza,
meningitis, rubella, pertussis
airborne precautions - ANSWER private room AIIR; respirator mask, fittings
tuberculosis, measles, varicella, SARS
vector-borne precautions - ANSWER Vectors are living creatures that carry pathogens,
such as rats, insects or birds
EX: mosquitoes transmitting malaria
Normal WBC count - ANSWER 5,000-10,000
shift to the left - ANSWER leftward shift in the granulocytic differential count; considered
a strong indication of bacterial infection
Positive regard - ANSWER underlying assumption is that the person is worthwhile and
has value and dignity; avoids unnecessary labeling
goals of nurse-patient relationship - ANSWER meeting pts needs, help identify feelings
and concerns, solve problems, cope and adapt in relation to situation
termination phase - ANSWER review of health changes and how the patient has dealt
with physical and emotional responses; includes discharge planning
Non Therapeutic Responses - ANSWER Rescue feelings
False reassurance
Giving advice
Changing the subject
Being moralistic
Nonprofessional involvement
PIE Note - ANSWER Problem, Intervention, Evaluation
Simplifies documentation by incorporating the plan of care into the progress notes
Increased efficient and flexibility; better care planning focus; better tracking of patient
problem, nursing interventions and patient outcomes; less redundancy
,SOAP Note - ANSWER subjective, objective, assessment, plan
Progress note that relates to only one health problem
Incident Report - ANSWER Includes date and time of incident, events leading up to it,
patient's response, and a full nursing assessment
Not attached to patient's chart
TeamSTEPPS - ANSWER "Team Strategies and Tools to Enhance Performance and
Patient Safety"
Templates to organize and improve communication
I PASS the BATON - ANSWER I-introduction
P-patient
A-assessment
S-situation
S-safety concerns
B-background
A-actions
T-timing
O-ownership
N-next
CUS - ANSWER I am Concerned
I am Uncomfortable
This is a Safety issue
Principles of documentation - ANSWER CONFIDENTIAL
ACCURATE
CONCISE AND COMPLETE
OBJECTIVE-
ORGANIZED AND TIMELY-
SAFETY Goals 2020 - ANSWER - Identify patients correctly
- Communication among staff
- Use medications correctly
- Decrease infection risk
- Prevent mistakes in surgery
- Identify patient safety risks
- Use alarms safely
Restraint Indications and Ordering - ANSWER - Must be reordered every 24 hrs
- Assess for circulation continuously
- Use quick-release mechanism
, - Assess the cause; develop alternatives and implement them first
Adduction - ANSWER moving a joint or extremity toward the midline of the body
Abduction - ANSWER moving a joint or extremity away from the midline of the body
Ataxia - ANSWER lack of muscle coordination
Chorea - ANSWER spontaneous, brief, involuntary muscle twitching of the limbs or
facial muscles
Athetosis - ANSWER movement characterized by slow, irregular, twisting motions
Orthostatic hypotension - ANSWER low blood pressure that occurs upon standing up
Supine - ANSWER Flat on back
Indications: alternative for patient on bed rest, used after spine surgery and some spinal
anesthesia
Contraindications: patients with dyspnea or risk for aspiration
Fowler's - ANSWER Sitting with head raised
Indications: Improves cardiac output, promotes ventilation, and eases talking, eating
and watching TV
Contraindications: After spine or brain surgery
Semi-Fowler's - ANSWER Semi Sitting position with patient's head slightly elevated
Indications: Improves cardiac output, promotes ventilation, and eases talking, eating
and watching TV
Contraindications: After spine or brain surgery
Prone - ANSWER Face Down
Contraindications: After abdominal surgery, patients with respiratory or spinal problems
Side-lying - ANSWER Indications: Patients with pressure on bony prominences of the
back and sacral pressure sores
Contraindications: After hip replacement or other orthopedic surgeries
Sims' - ANSWER Semiprone, patient lays on side with weight distributed toward anterior
ilium, humerus and clavicle
Indications: enemas,
Contraindications: patients with spine or orthopedic conditions
Trenedelenburg's - ANSWER patient lies supine with head 30 to 40 degrees lower than
feet
Indications: postural drainage and to promote venous return
Contraindication: hypotension
Answers(GRADED A)
Indications for washing hands with soap and water - ANSWER Visibly dirty hands,
hands visibly soiled with body fluids; after using the toilet
Indications for alcohol-based hand sanitizer - ANSWER If hands are not visibly soiled,
before and after touching a pt, before handling an invasive device for pt care, after
contact with body fluids or secretions, mucous membranes, non intact skin, or wound
dressings, between contact with inanimate surfaces and objects and after removing
sterile or nonsterile gloves
Medical Asepsis - ANSWER "Clean technique"
- Used for procedures involving intact skin, non sterile body cavities (surfaces of the
mouth, GI tract, reproductive tract), and infected wounds
- Includes procedures such as infected or chronic wound care, nasopharyngeal
swabbing, routine gynecological exams
Surgical Asepsis - ANSWER "Sterile technique"
*To be sterile, an object must be free from all microorganisms*
- Used to prevent the introduction or spread of pathogens from the environment into the
patient
- Used for procedures involving entry into sterile body cavities, organs vascular spaces
or across mucous membranes
(Insertion of IV catheters, injections, urinary catheterization, some irrigation of drainage
tubes, all operative procedures)
Chain of Infection - ANSWER infectious agent, reservoir, portal of exit, mode of
transmission, portal of entry, susceptible host
Progress of Infection (Periods) - ANSWER Incubation period
Prodromal period
Acute phase
Convalescent period
Contact Precautions - ANSWER private room, clean gloves, gown
multidrug resistant organisms; infectious diarhhea (C.Diff, shigella, Norovirus);
infectious skin conditions (impetigo, herpes, S.aureus)
Vehicle Precautions - ANSWER involves the transfer of pathogens by way of vehicles or
contaminated items
,(food can carry Salmonella, water can carry Legionella, drugs can carry bacteria from
contaminated infusion supplies, non sterile surgical instruments can carry pathogens
into surgical incisions, and blood can carry hepatitis and HIV)
droplet precautions - ANSWER private room or cohab, mask within 3 feet, masks for
providers and visitors
transmission of large droplets through sneezing, coughing, or talking: influenza,
meningitis, rubella, pertussis
airborne precautions - ANSWER private room AIIR; respirator mask, fittings
tuberculosis, measles, varicella, SARS
vector-borne precautions - ANSWER Vectors are living creatures that carry pathogens,
such as rats, insects or birds
EX: mosquitoes transmitting malaria
Normal WBC count - ANSWER 5,000-10,000
shift to the left - ANSWER leftward shift in the granulocytic differential count; considered
a strong indication of bacterial infection
Positive regard - ANSWER underlying assumption is that the person is worthwhile and
has value and dignity; avoids unnecessary labeling
goals of nurse-patient relationship - ANSWER meeting pts needs, help identify feelings
and concerns, solve problems, cope and adapt in relation to situation
termination phase - ANSWER review of health changes and how the patient has dealt
with physical and emotional responses; includes discharge planning
Non Therapeutic Responses - ANSWER Rescue feelings
False reassurance
Giving advice
Changing the subject
Being moralistic
Nonprofessional involvement
PIE Note - ANSWER Problem, Intervention, Evaluation
Simplifies documentation by incorporating the plan of care into the progress notes
Increased efficient and flexibility; better care planning focus; better tracking of patient
problem, nursing interventions and patient outcomes; less redundancy
,SOAP Note - ANSWER subjective, objective, assessment, plan
Progress note that relates to only one health problem
Incident Report - ANSWER Includes date and time of incident, events leading up to it,
patient's response, and a full nursing assessment
Not attached to patient's chart
TeamSTEPPS - ANSWER "Team Strategies and Tools to Enhance Performance and
Patient Safety"
Templates to organize and improve communication
I PASS the BATON - ANSWER I-introduction
P-patient
A-assessment
S-situation
S-safety concerns
B-background
A-actions
T-timing
O-ownership
N-next
CUS - ANSWER I am Concerned
I am Uncomfortable
This is a Safety issue
Principles of documentation - ANSWER CONFIDENTIAL
ACCURATE
CONCISE AND COMPLETE
OBJECTIVE-
ORGANIZED AND TIMELY-
SAFETY Goals 2020 - ANSWER - Identify patients correctly
- Communication among staff
- Use medications correctly
- Decrease infection risk
- Prevent mistakes in surgery
- Identify patient safety risks
- Use alarms safely
Restraint Indications and Ordering - ANSWER - Must be reordered every 24 hrs
- Assess for circulation continuously
- Use quick-release mechanism
, - Assess the cause; develop alternatives and implement them first
Adduction - ANSWER moving a joint or extremity toward the midline of the body
Abduction - ANSWER moving a joint or extremity away from the midline of the body
Ataxia - ANSWER lack of muscle coordination
Chorea - ANSWER spontaneous, brief, involuntary muscle twitching of the limbs or
facial muscles
Athetosis - ANSWER movement characterized by slow, irregular, twisting motions
Orthostatic hypotension - ANSWER low blood pressure that occurs upon standing up
Supine - ANSWER Flat on back
Indications: alternative for patient on bed rest, used after spine surgery and some spinal
anesthesia
Contraindications: patients with dyspnea or risk for aspiration
Fowler's - ANSWER Sitting with head raised
Indications: Improves cardiac output, promotes ventilation, and eases talking, eating
and watching TV
Contraindications: After spine or brain surgery
Semi-Fowler's - ANSWER Semi Sitting position with patient's head slightly elevated
Indications: Improves cardiac output, promotes ventilation, and eases talking, eating
and watching TV
Contraindications: After spine or brain surgery
Prone - ANSWER Face Down
Contraindications: After abdominal surgery, patients with respiratory or spinal problems
Side-lying - ANSWER Indications: Patients with pressure on bony prominences of the
back and sacral pressure sores
Contraindications: After hip replacement or other orthopedic surgeries
Sims' - ANSWER Semiprone, patient lays on side with weight distributed toward anterior
ilium, humerus and clavicle
Indications: enemas,
Contraindications: patients with spine or orthopedic conditions
Trenedelenburg's - ANSWER patient lies supine with head 30 to 40 degrees lower than
feet
Indications: postural drainage and to promote venous return
Contraindication: hypotension
