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Theoretical Foundation in Nursing Practice
NUR 215 Exam 2 SPRING-SUMMER 2025
ARIZONA COLLEGE OF NURSING (module 3- 5 )
@Question and Answer
A charge nurse is reviewing with a newly hired nurse the difference in manifestations of a localized vs a systemic infection. Which of the following are manifestations of a systemic infection. (select all that apply) A. Fever B. Malaise C. Edema D. Pain or tenderness E. Increase in pulse and respiratory rate A. Fever B. Malaise E. Increase in pulse and respiratory rate A nurse is contributing to the plan of care for a client who is being admitted to the facility w/a suspected diagnosis of pertussis. Which of the following should the nurse include in the plan of care? Select all.
Theoretical Foundation in Nursing Practice
A. Place the client in a room that has negative air pressure of at least 6 exchanges/hr B. Wear a mask when providing care within 3 ft of the client C. Place a surgical mask on the client if transportation to another dept is unavoidable D. Use sterile gloves when handling soiled linens E. Wear a gown when preforming care that may result in contamination from secretions B. Wear a mask when providing care within 3 ft of the client C. Place a surgical mask on the client if transportation to another dept is unavoidable E. Wear a gown when preforming care that may result in contamination from secretions What is an infection? occurs when a pathogen is present and leads to a chain of events What is the best prevention against HAIs? Hand hygiene
Theoretical Foundation in Nursing Practice
What is the reservoir in the chain of infection? where pathogens can live and multiply, ex. human, animal, food, or organic matter what is the portal of exit in the chain of infection? where the pathogen can leave the reservoir and spread ex body fluids, respiratory, GI tract, skin, MM A nurse is caring for a client who has severe acute respiratory syndrome (SARS). The nurse knows that health care professional are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (select all the apply) A. Planning and evaluating control and prevention strategies B. Determining public health priorities C. Ensuring proper medical treatment D. Identifying endemic disease E. Monitoring for common-source outbreaks A. Planning and evaluating control and prevention strategies B. Determining public health priorities
Theoretical Foundation in Nursing Practice
D. Identifying endemic disease E. Monitoring for common-source outbreaks A nurse is caring for a client who has had a cough for 3 weeks and is beginning to cough up blood. The client has manifestations of which of the following conditions? A. allergic reaction B. ringworm C. systemic lupus erythematosus D. Tuberculosis D. Tuberculosis A nurse is caring for a client who repots a severe throat, pain when swallowing, and swollen lymph nodes. The client has manifestations of which of the following conditions? A. prodromal B. ringworm C. convalescence
Theoretical Foundation in Nursing Practice
Positive culture Contact transmission examples D+, CDF, open wounds, and MRSA Droplet Transmission examples Pneumonia, pertussis, strep, COVID-larger than 5cmg, and RSV Airborne examples Covid-smaller than 5mcg, measles, TB, Varicella vector transmission lyme, mosquito transmission, west nile, and malaria hand hygiene Wash hands with antimicrobial soap when in contact with contaminants,
Theoretical Foundation in Nursing Practice
do not use soap and water, not alcohol if C. Diff is suspected Cough etiquette Using facial tissues to contain respiratory secretions & prompt disposal Weaning surgical mask when coughing to minimize contamination of surrounding area Turning head when coughing and staying a minimum distance of 3 feet away from others Performing hand hygiene after contact with respiratory secretions or contaminated objects standard precautions (tier 1) Protect against the spread of infection through blood, body fluids, mucous membranes and non-intact skin Must be used for all patients Applies to all body fluids except sweat, non-intact skin, and MM
Theoretical Foundation in Nursing Practice
Droplet Transmission Precautions Droplets larger than 5mcg and can travel 3-6ft from the client Streptococcal pharyngitis, pneumonia, haemophilus influenzae type B, scarlet fever, rubella, pertussis, mumps, meningococcal pneumonia Private room Masks for providers and visitors Wear a mask when outside of the room Airborne transmission precautions Droplets less than 5mcg measles, varicella, pulmonary or laryngeal tuberculosis Require a private room, masks and respiratory protection
Theoretical Foundation in Nursing Practice
N95 or HEPA respirator if the client might have TB Negative pressure airflow exchange in the room Full face protection if body fluid splashing may occur Clients should wear a mask when outside of room Positive pressure vs negative pressure rooms Risk factors for infection
- Inadequate hand hygiene
- Immunocompromised
- Recent surgery
- Break in skin
- Indwelling device
- Smoking or alcohol consumption
- Older adults
Theoretical Foundation in Nursing Practice
D. Use over-the-counter products to treat abrasions E. Wear cotton socks A. Inspect the feet daily B. Use moisturizing lotion on the feet (not in-between toes) E. Wear cotton socks A nurse is planning care for a client who develops dyspnea and feels tired after completing morning care. Which of the following guidelines should the nurse include. Select all that apply A. Schedule rest periods during morning care B. Discontinue morning care for 2 days C. Perform all care as quickly as possible D. Ask a family member to come in to bathe the client A. Schedule rest periods during morning care A nurse is beginning a complete bed bath for a client. After removing the client's gown and placing a bath blanket over the body, which of the following areas should the nurse wash first? A. face
Theoretical Foundation in Nursing Practice
B. feet C. chest D. arms A. face A nurse is preparing to perform denture care for a client. Which of the following actions should the nurse plan to take? A. Pull down and out at the back of the upper denture to remove B. Brush the dentures with a toothbrush and denture cleaner C. Rinse the dentures with hot water after cleaning them D. Place the dentures in a clean, dry storage container after cleaning them B. Brush the dentures with a toothbrush and denture cleaner What are 5 benefits of good hygiene?
- promotes comfort
- improves self body image
- decreases infection and disease
- promotes autonomy
Theoretical Foundation in Nursing Practice
Early morning care-On awakening, wash face, hands and mouth care AM care-After breakfast, bathing, toileting, hair, skin and bed making PM care-Toileting, handwashing, oral care, readying for visitors HS care-Prior to sleep, relaxation, activism reading environment to facilitate sleep What are the different types of baths administered in the hospital setting? Assist bath- Areas hard to reach Complete bath Partial bath-Bathe only areas absolutely necessary include peritoneal, a complete bath may be too stressful Towel bath Bag/ package
Theoretical Foundation in Nursing Practice
Shower Tub bath Therapeutic bath-Eczema, diaper rash important factors to remember while preforming oral care Decreases risk of infection that causes pneumonia, risk for aspiration, impaired swallowing or decreased gag reflex important factors to remember when performing oral care on altered patient have suction ready, do not place fingers in the mouth, keep head turned to one side important factors of foot care
Theoretical Foundation in Nursing Practice
Check from cracking, clubbing, and fungus Do not soak due to infection File nails instead of cutting Acute pain characteristics protective, temporary, usually self-limiting has a direct cause Physiologic response (sympathetic nervous system) tachycardia, hypertension, anxiety, diaphoresis, muscle tension Behavioral response- grimacing, moaning, flinching, and guarding Management aims to treat cause Chronic pain characteristics ongoing or recurs frequently, lasting longer than 6 months
Theoretical Foundation in Nursing Practice
Physiological responses do not affect vital signs, clients can have depression, fatigue and a decreased level of functioning Management aims to treat symptomatic pain idiopathic pain a chronic pain w/o a known cause ex. migraine or joint nociceptive pain characteristics arises from damage or inflammation of tissue, which triggers nociceptors and causes pain Typically acute pain, responds to pain medication Throbbing, aching or localizing Three types of nociceptive pain Somatic- pain in bone, muscle, joints or connective tissue
