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NR 224 Final Exam (Answered) 341 Questions and Correct Answers, 100% Correct, Latest 2024/2025. $15.99   Add to cart

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NR 224 Final Exam (Answered) 341 Questions and Correct Answers, 100% Correct, Latest 2024/2025.

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NR 224 Final Exam (Answered) 341 Questions and Correct Answers, 100% Correct, Latest 2024/2025.

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  • October 3, 2024
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NR 224 Final Exam (Answered) 341
Questions and Correct Answers, 100%
Correct, Latest 2024/2025.
Who is at increased risk of infection?

-elderly
-infants
-immobility
-autoimmune
-malnourished
-immunocompromised
-transplant
-chemo
-HIV
-steroids

Body's Natural Defenses

-skin
-mucus membranes
-saliva/tears/sweat
-inflammation
-GI/GU (flushing)
-immune system
-respiratory tract (cilia/cough)

What is the nurses role in infection control?

assess, education, use proper precautions

Chain of Infection

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

-bacteria, virus, protozoa, fungus
-resident flora: bacteria that is already present

,-transient flora: attaches to the skin -> causes infection
-virulence: strength

Reservoir

-H2O, body fluids, animals, insects, food, people
-needs proper environment (temp, pH, light, O2)

Portal of Exit

-body fluids, respiratory tract, GI, GU, mucus membranes, skin, blood, transplacental

Mode of Transmission

-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

standard precautions: hand-washing, gloves, needle safety, proper disposal of biohazard

Tier 2

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

-preferably same as exit

Susceptible Host

-ability to get infection, vaccinations make host lest susceptible

Surgical Asepsis

-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

,-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

-elderly, obesity, neuro issues, same as list for increased risk for infection

Braden Scale

checks for risk of skin breakdown, the more points, the less likely for skin breakdown, 12 or less = high
risk




Pressure Ulcers

-capillary displacement -> lack of blood flow = lack of O2 -> ischemia -> necrosis

Factors for Pressure Ulcers

-intensity: intense pressure or light pressure over a long time
-duration
-tolerance: how strong is skin, health, malnourished?

Stage I Pressure Ulcer

-non-blanchable erythema




Stage II Pressure Ulcer

-partial thickness loss of dermis
-shallow open ulcer with red pink wound bed
-open or intact blister

, Stage III Pressure Ulcer

-full thickness skin loss
-subcutaneous fat may be visible
-tunneling or undermining




Stage IV Pressure Ulcer

-full thickness tissue loss
-visible muscle, bone, tendon
-undermining




Describing a Wound

-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

-friction (a force that occurs in a direction to oppose movement), force exerted against the skin while the
skin remains stationary

Skin Tear

tear in skin from something

Prevention of Skin Breakdown

-nutrition, change brief consistently (acidity), barrier cream

Types of Wound Healing

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