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NUR211 FUNDAMENTALS EXAM 2 STUDY GUIDE VERSION 2 / NUR 211 FUNDAMENTALS EXAM 2 STUDY GUIDE VERSION 2 (LATEST 2021) | RASMUSSEN COLLEGE $14.49
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Exam 2 Concept Guide
Safety virus, adenovirus, respiratory
syncytial virus)
Infection control precautions
guidelines and when to utilize -PPE use:
*Contact -Wear a facemask for close contact
with the patient; the facemask should
-Examples: Presence of stool
be put on upon entering the exam
incontinence (may include patients
room
with norovirus, rotavirus,
or Clostridium difficile), draining -If extensive spraying of respiratory
wounds, uncontrolled secretions, fluids is predicted, gloves and gown
pressure ulcers, or presence of ostomy as well as goggles (or face shield in
tubes and/or bags draining body fluids place of goggles) should be worn
-Perform hand hygiene before -Eye protection is utilized if irrigating
touching patient and prior to wearing a wound or if a specimen is needed
gloves with those with a respiratory virus
-PPE use: -Perform hand hygiene before and
after touching the patient and after
-Wear gloves when touching the
contact with respiratory secretions
patient and the patient’s immediate
and contaminated
environment or belongings. *Wear a
objects/materials; note: use soap and
gown if substantial contact with the
water when hands are visibly soiled
patient or their environment is
(e.g., blood, body fluids)
anticipated, such as with active
MRSA patients -Instruct patient to wear a facemask
when exiting the exam room, avoid
-Perform hand hygiene after removal
coming into close contact with other
of PPE; note: use soap and water
patients, and practice respiratory
when hands are visibly soiled (e.g.,
hygiene and cough etiquette
blood, body fluids), or after caring for
patients with known or suspected *Airborne
infectious diarrhea (e.g., Clostridium
-Examples Tuberculosis, Measles,
difficile, norovirus)
Chickenpox (until lesions are crusted
*Droplet over), Localized (in
immunocompromised patient) or
-Examples Respiratory viruses
disseminated herpes zoster (until
(influenza, pertussis, parainfluenza
lesions are crusted over)
,NUR 211 FUNDAMENTALS EXAM 2 STUDY GUIDE VERSION 1
Exam 2 Concept Guide
-Place the patient immediately in an present in the environment or
airborne infection isolation room transmitted from other people.
(AIIR)
-As with all patients, standard
-If an AIIR is not available: Provide a precautions are required, but some
facemask (e.g., procedure or surgical additional measures are helpful when
mask) to the patient and place the a patient’s ability to withstand any
patient immediately in an exam room bacterial invasion is compromised.
with a closed door
Recommendations in this situation
-PPE use: include:
-Wear a fit-tested N-95 -Ensure that caregiver is healthy.
-If substantial spraying of respiratory -Restrict visits from friends and
fluids is anticipated, gloves and gown family members who have colds or
as well as goggles or face shield contagious illnesses.
should be worn
-Avoid collection of standing water in
-Perform hand hygiene before and the room (e.g., with flowers or in
after touching the patient and after humidifiers) to prevent bacteria
contact with respiratory secretions typically found in this water.
and/or body fluids and contaminated
-The latest CDC isolation guidelines
objects/materials; note: use soap and
also address environmental controls
water when hands are visibly soiled
that foster a “protective environment”
(e.g., blood, body fluids)
to decrease the risk of infection in the
*Special precautions most severely immunocompromised
patients.
-Nurses need to use neutropenic
precautions/protective for a patient Skin breakdown risks
whose immune system is
- Immobility
compromised (e.g., recovering from
transplantation surgery or receiving - Poor Nutrition and Hydration
chemotherapy or heart transplant). - Decreased Moisture
-Those who are immunosuppressed - Decreased Mental Status
more often than not become infected
by organisms harbored in their own - Increased Age
bodies, rather than by pathogens Ways to avoid friction/shear
, NUR 211 FUNDAMENTALS EXAM 2 STUDY GUIDE VERSION 1
Exam 2 Concept Guide
Friction- occurs when two surfaces Proper specimen teaching and
rub against each other collection for sputum, urine,
Shear- results when one layer of *Routine Urinalysis
tissue slides over another layer, shear
-A sterile urine specimen is not
separates the skin from underlying
required for a routine urinalysis.
tissue
-Collect urine by having the patient
- Use of lift sheet to reduce shearing
void into a clean bedpan, urinal, or
or USE A MECHANICAL
receptacle (e.g., a specimen hat in the
LIFT….so… we need to evaluate
toilet bowl). Take care to avoid
self-mobility ability
contamination with feces.
Use of Braden scale
-If a woman is menstruating when a
Used for predicting pressure sore urine sample is obtained, note this on
ulcer risk. the laboratory slip because red blood
cells may appear in the urine.
Higher score = less risk
-Using aseptic technique, pour the
19 – 23 No risk
urine into an appropriate container;
15 – 18 Mild label it with the patient’s name, date,
13 – 14 Moderate and time of collection; package it
appropriately; and send it to the
10 – 12 High laboratory for examination.
Below 9 Very High -Do not leave urine standing at room
temperature for a long period before
sending it to the laboratory because
this may alter both the appearance and
chemistry of the urine.
*Clean Catch or Midstream
Specimen
-Small amount of urine is urinated,
then the urine is collected mid-stream
of urinating. Done with a sterile
specimen container and finish
urinating in same container
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