ADULT CCRN CERTIFICATION MODULE 10 INTEGUMENTARY AND MUSCOSKELETAL 4 PRACTICE TESTS 2024, Exams of Nursing

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ADULT CCRN CERTIFICATION

MODULE 10

INTEGUMENTERY AND MUSCOSKELETAL

4 PRACTICE TESTS

1. What is the most common cause of cellulitis?

a) Staphylococcus aureus

b) Streptococcus pyogenes

c) Pseudomonas aeruginosa

d) Escherichia coli

Answer: b) Streptococcus pyogenes

Rationale: Cellulitis is a bacterial infection of the skin and subcutaneous

tissues, usually caused by streptococci or staphylococci. Streptococcus

pyogenes is the most common cause of cellulitis, especially in the lower

extremities.

2. Which of the following is a risk factor for developing IV infiltration?

a) Using a large-bore catheter

b) Inserting the catheter in an area of flexion

c) Securing the catheter with tape

d) Flushing the catheter with saline

Answer: b) Inserting the catheter in an area of flexion

Rationale: IV infiltration occurs when the IV fluid or medication leaks into the

surrounding tissue, causing swelling, pain, and tissue damage. Risk factors

for IV infiltration include using a small-bore catheter, inserting the catheter in

an area of flexion, such as the antecubital fossa, using an unstable vein, and

infusing vesicant or irritating solutions.

3. What is the hallmark sign of necrotizing fasciitis?

a) Fever and chills

b) Erythema and edema

c) Crepitus and gas formation

d) Purulent and foul-smelling discharge

Answer: c) Crepitus and gas formation

Rationale: Necrotizing fasciitis is a rare but life-threatening infection of the

skin, subcutaneous tissue, and fascia, caused by anaerobic bacteria that

produce gas and toxins. The hallmark sign of necrotizing fasciitis is crepitus

and gas formation under the skin, which can be palpated or heard with a

stethoscope. Other signs and symptoms include fever, chills, severe pain,

erythema, edema, blisters, necrosis, and systemic toxicity.

4. What is the most reliable method to assess the depth of a pressure

injury?

a) Measuring the length and width of the wound

b) Using a wound classification system

c) Visualizing the wound bed and tissue types

d) Performing a tissue biopsy

Answer: c) Visualizing the wound bed and tissue types

Rationale: Pressure injuries are localized damage to the skin and underlying

tissue caused by prolonged pressure or shear forces. The depth of a

pressure injury depends on the extent of tissue loss and exposure of

underlying structures, such as muscle, bone, or tendon. The most reliable

method to assess the depth of a pressure injury is to visualize the wound

bed and identify the types of tissue present, such as granulation, slough,

eschar, or necrotic tissue.

5. What is the best way to prevent wound infection?

a) Applying topical antibiotics

b) Using sterile dressings

c) Performing wound irrigation

d) Maintaining a moist wound environment

Answer: d) Maintaining a moist wound environment

Rationale: Wound infection is a complication of wound healing that can delay

healing, increase pain, and cause systemic illness. The best way to prevent

wound infection is to maintain a moist wound environment that promotes

granulation and epithelialization, while preventing dehydration and bacterial

colonization. Topical antibiotics are not recommended for routine use as they

can cause allergic reactions, bacterial resistance, and toxicity. Sterile dressings

are not necessary for clean wounds as they can increase costs and waste.

Wound irrigation can be used to remove debris and bacteria from contaminated

wounds, but it can also damage healthy tissue if done too forcefully or too

frequently.

1. Which of the following statements is true about cellulitis?

A. Cellulitis is an infection of the deep layers of the skin and subcutaneous

tissues.

B. Cellulitis is caused by vasospasms leading to compromised blood flow

and tissue necrosis.

C. Cellulitis typically presents with severe pain and blistering rash.

D. Cellulitis is commonly caused by allergic reactions to certain medications.

Answer: A. Cellulitis is an infection of the deep layers of the skin and

subcutaneous tissues.

Rationale: Cellulitis is a bacterial infection that affects the deeper layers of

the skin and underlying tissues. It causes redness, inflammation, warmth,

tenderness, and swelling at the affected site. Vasospasms, blistering rash,

and allergic reactions are not associated with cellulitis.

2. What is the most appropriate initial nursing intervention when a patient

develops an infiltrated intravenous (IV) site?

A. Remove the infiltrated IV catheter immediately.

B. Apply a warm compress to the infiltrated area.

C. Elevate the affected extremity above heart level.

D. Flush the infiltrated area with a sterile saline solution.

Answer: A. Remove the infiltrated IV catheter immediately.

Rationale: When an IV site becomes infiltrated, the first step is to remove the

infiltrated IV catheter to prevent further tissue damage. Applying heat,

elevating the extremity, or flushing the area with saline would not address

the underlying issue of infiltration.

3. Which of the following represents a characteristic feature of necrotizing

fasciitis?

A. Rapid spread of infection through the epidermal layer.

B. Formation of hardened scar tissue at the infection site.

C. Destruction of the superficial layers of the skin only.

D. Deep tissue involvement with severe pain and necrosis.

Answer: D. Deep tissue involvement with severe pain and necrosis.

Rationale: Necrotizing fasciitis is a rapidly progressing bacterial infection that

affects the deep layers of the skin, subcutaneous tissues, and fascia. It

causes severe pain, rapid tissue destruction, and necrosis. Infection spreads

through the superficial fascial layers, rather than just the epidermal layer,

and does not lead to scar tissue formation.

4. A patient at risk for developing pressure injuries requires frequent

repositioning. Which position should the nurse prioritize to reduce pressure

on the coccyx?

A. Sim's position.

B. Supine position.

C. Prone position.

D. Fowler's position.

Answer: A. Sim's position.

Rationale: Sim's position, also known as lateral position, helps reduce

pressure on the coccyx (tailbone) by shifting the patient's weight distribution.

Supine position, prone position, and Fowler's position do not specifically

alleviate pressure on the coccyx area.

5. Which statement accurately describes a Stage II pressure injury?

A. Full-thickness tissue loss with visible fat.

B. Partial-thickness skin loss with exposed dermis.

C. Non-blanchable erythema of intact skin.

D. Ulcer extending to muscle or bone.

Answer: B. Partial-thickness skin loss with exposed dermis.

Rationale: A Stage II pressure injury involves partial-thickness skin loss,

manifesting as a shallow open ulcer with a red-pink wound bed or exposed

dermis. Full-thickness tissue loss with visible fat characterizes Stage III

pressure injuries, non-blanchable erythema represents Stage I, and ulcers

involving muscle or bone indicate Stage IV.

6. What is the most appropriate nursing intervention for a patient with a

clean, healing surgical wound?

A. Apply sterile saline-soaked dressings.

B. Cleanse the wound using hydrogen peroxide.

C. Leave the wound open to air for prolonged periods.

D. Apply sterile, occlusive dressings.

Answer: D. Apply sterile, occlusive dressings.

Rationale: For clean, healing surgical wounds, the use of sterile, occlusive

dressings helps maintain a moist environment that facilitates wound healing

and reduces the risk of infection. Applying saline-soaked dressings, using

hydrogen peroxide, or leaving the wound open to air may delay or interfere

with the healing process.

7. What is the primary goal when managing a moderate to severe pressure

injury?

A. Minimizing further tissue damage and promoting granulation.

B. Preventing infection through regular dressing changes.

C. Facilitating rapid wound closure through surgical intervention.

D. Promoting wound drainage to prevent accumulation of necrotic tissue.

Answer: A. Minimizing further tissue damage and promoting granulation.

Rationale: The primary goal in managing moderate to severe pressure

injuries is to minimize further tissue damage and promote granulation (the

formation of new blood vessels and connective tissue). Preventing infection

and facilitating wound closure through surgical intervention are also

important but secondary goals. Promoting wound drainage is necessary, but

it does not address the primary goal.

8. Which statement is true regarding the assessment of an arterial ulcer?

A. Arterial ulcers typically have surrounding erythema and warmth.

B. Arterial ulcers often occur on the lower extremities and have pale

granulation tissue.

C. Arterial ulcers are deeply pigmented with irregular borders.

D. Arterial ulcers present with moderate to severe pain at rest.

Answer: D. Arterial ulcers present with moderate to severe pain at rest.

Rationale: Arterial ulcers are typically located on the lower extremities and

have pale granulation tissue or absent granulation. They are not associated

with surrounding erythema, warmth, deep pigmentation, or irregular borders.

The characteristic symptom of arterial ulcers is moderate to severe pain,

which worsens at rest.

9. A patient with a pressure injury is prescribed topical wound care. The

nurse should:

A. Apply the prescribed dressing every other day to allow the wound to

"breathe."

B. Cleanse the wound using povidone-iodine solution before each dressing

change.

C. Decrease the frequency of dressing changes if the wound appears dry.

D. Apply the dressing starting from the periphery and moving toward the

wound center.

Answer: D. Apply the dressing starting from the periphery and moving

toward the wound center.

Rationale: To promote proper healing and avoid contamination, the nurse

should apply the dressing from the periphery toward the wound center,

minimizing the risk of introducing microorganisms into the wound. Dressings

should be changed according to the healthcare provider's orders, wounds

should not be left open every other day. Povidone-iodine solution may

damage healthy tissue, so cleansing should be performed using a

prescribed solution. If the wound appears dry, the frequency of dressing

changes may need to be increased.

10. Which action by the nurse demonstrates appropriate prevention of IV

infiltration?

A. Regularly palpating IV sites for coolness, swelling, or tenderness.

B. Selecting a small gauge needle for IV insertion in patients with fragile

veins.

C. Limiting fluid administration to prevent fluid overload.

D. Applying a cold compress to the IV site.

Answer: A. Regularly palpating IV sites for coolness, swelling, or

tenderness.

Rationale: Regularly palpating IV sites for coolness, swelling, or tenderness

is an appropriate nursing action to assess for potential infiltration. Selecting

a small gauge needle for fragile veins may increase the risk of infiltration.

Limiting fluid administration may not be necessary unless specifically

ordered by the healthcare provider. Applying a cold compress to the IV site

is not recommended, as it could cause vasoconstriction and impair blood

flow.

11. A patient presents with signs and symptoms of cellulitis, including

erythema, edema, warmth, and pain. Which nursing intervention is most

appropriate?

A. Elevate the affected limb to reduce swelling.

B. Administer an antihistamine to alleviate pain.

C. Apply a moist heat pack to the area.

D. Initiate isolation precautions to prevent transmission.

Answer: A. Elevate the affected limb to reduce swelling.

Rationale: Elevating the affected limb can help reduce edema and swelling

associated with cellulitis. Antihistamines are not typically prescribed for

cellulitis, as it is not an allergic reaction. Moist heat packs may potentially

worsen the infection. Isolation precautions are not necessary for cellulitis, as

it is not typically transmitted from person to person.

12. Which factor increases the risk of developing a pressure injury?

A. High body mass index (BMI)

B. Increased oral intake of vitamin C

C. Frequent ambulation

D. Elastic compression stockings

Answer: A. High body mass index (BMI)

Rationale: A high body mass index (BMI) places individuals at an increased

risk for developing pressure injuries, as the excess weight adds pressure on

certain areas of the body. Increased intake of vitamin C and frequent

ambulation can help prevent pressure injuries. Elastic compression

stockings do not directly affect pressure injury risk.

13. Which statement accurately describes a pressure injury?

A. Pressure injuries can develop without applying prolonged pressure to the

skin.

B. Pressure injuries primarily affect the muscles and bones.

C. Pressure injuries tend to heal rapidly with minimal intervention.

D. Pressure injuries are always caused by significant trauma or accidents.

Answer: A. Pressure injuries can develop without applying prolonged

pressure to the skin.

Rationale: Pressure injuries can occur from even brief periods of pressure

due to compromised blood flow to the tissues. They affect the skin and

underlying tissues, not just muscles and bones. Pressure injuries often

require intensive interventions and may heal slowly. They are not always

caused by trauma or accidents.

14. Which nursing intervention is essential when providing care for a patient

with a necrotizing fasciitis infection?

A. Administering broad-spectrum antibiotics as prescribed.

B. Applying warm compresses to the infected area.

C. Keeping the affected limb elevated above the heart.

D. Promoting frequent range of motion exercises.

Answer: A. Administering broad-spectrum antibiotics as prescribed.

Rationale: Broad-spectrum antibiotics are essential in the treatment of

necrotizing fasciitis to combat the severe bacterial infection. Applying warm

compresses may worsen the condition. Elevation of the affected limb is not a

primary intervention for necrotizing fasciitis. Range of motion exercises

should be avoided to prevent further damage to the affected area.

15. What is the main nursing priority when providing care for a patient with a

wound?

A. Promoting wound closure by frequent debridement.

B. Preventing infection through proper wound cleansing and dressing.

C. Reducing pain through the administration of analgesics.

D. Maintaining accurate documentation of wound characteristics.

Answer: B. Preventing infection through proper wound cleansing and

dressing.

Rationale: The main nursing priority when caring for a wound is preventing

infection by adhering to proper wound cleansing and dressing techniques.

Frequent debridement may be appropriate for some wounds, but it does not

take precedence over preventing infection. Reducing pain and documenting

wound characteristics are important but secondary priorities.

Which of the following is a characteristic feature of cellulitis?

a. Presence of blisters

b. Involvement of subcutaneous tissue

c. Limited to the epidermis

d. Associated with frostbite

Answer: b. Involvement of subcutaneous tissue

Rationale: Cellulitis is a bacterial infection that affects the skin and

subcutaneous tissues, leading to redness, swelling, and warmth in the

affected area.

Which of the following signs is indicative of IV infiltration?

a. Warmth and redness along the vein

b. Swelling and pain at the insertion site

c. Slow or stopped infusion flow

d. Coolness and pallor at the insertion site

Answer: d. Coolness and pallor at the insertion site

Rationale: IV infiltration can cause coolness, pallor, and swelling at the

insertion site due to the infiltration of fluid into the surrounding tissues.

What is the primary cause of necrotizing fasciitis?

a. Viral infection

b. Fungal overgrowth

c. Bacterial infection

d. Allergic reaction

Answer: c. Bacterial infection

Rationale: Necrotizing fasciitis is a severe bacterial infection that affects

the fascia and subcutaneous tissues, leading to tissue necrosis and

systemic toxicity.

A nurse is assessing a patient at risk for pressure injuries. Which factor

contributes to the development of pressure injuries?

a. Increased mobility

b. Adequate tissue perfusion

c. Prolonged pressure over bony prominences

d. Elastic support surfaces

Answer: c. Prolonged pressure over bony prominences

Rationale: Pressure injuries result from prolonged pressure on the skin

and underlying tissues, often over bony prominences, leading to tissue

ischemia and damage.

What type of wound healing occurs in an open wound with minimal tissue

loss?

a. Primary intention

b. Secondary intention

c. Tertiary intention

d. Regenerative healing

Answer: a. Primary intention

Rationale: Primary intention healing occurs in wounds with minimal tissue

loss, where the wound edges are approximated and healing occurs with

minimal scarring.

A patient with cellulitis is prescribed antibiotic therapy. Which class of

antibiotics is commonly used to treat cellulitis?

a. Aminoglycosides

b. Macrolides

c. Penicillins

d. Sulfonamides

Answer: c. Penicillins

Rationale: Penicillins, such as amoxicillin and ampicillin, are commonly

used to treat cellulitis due to their effectiveness against the bacteria

commonly involved in cellulitis.

What is the priority nursing intervention for a patient experiencing IV

infiltration?

a. Remove the IV catheter immediately

b. Apply a warm compress to the insertion site

c. Elevate the affected extremity

d. Administer a prescribed antidote

Answer: a. Remove the IV catheter immediately

Rationale: The priority nursing intervention for IV infiltration is to remove

the IV catheter to prevent further infiltration and tissue damage.

Which bacterial pathogen is commonly associated with necrotizing fasciitis?

a. Staphylococcus aureus

b. Pseudomonas aeruginosa

c. Streptococcus pyogenes

d. Clostridium perfringens

Answer: c. Streptococcus pyogenes

Rationale: Necrotizing fasciitis is often caused by Streptococcus

pyogenes, although other bacteria such as Staphylococcus aureus can also

be implicated.

A patient is at risk for developing a pressure injury. What is the most

effective preventive measure for this patient?

a. Repositioning the patient every 4 hours

b. Using a pressure-reducing mattress

c. Applying moisture barriers to bony prominences

d. Massaging bony prominences regularly

Answer: b. Using a pressure-reducing mattress

Rationale: Using a pressure-reducing mattress helps distribute pressure

evenly and reduces the risk of pressure injury development in at-risk

patients.

What is a characteristic feature of a stage 3 pressure injury?

a. Skin loss involving epidermis and dermis

b. Full-thickness skin loss with visible fat

c. Partial-thickness skin loss with exposed bone

d. Intact skin with non-blanchable erythema

Answer: b. Full-thickness skin loss with visible fat

Rationale: A stage 3 pressure injury involves full-thickness skin loss with

visible adipose (fat) tissue but does not extend through underlying fascia.

Which wound dressing is most appropriate for a patient with a stage 2

pressure injury?

a. Alginate dressing

b. Hydrocolloid dressing

c. Transparent film dressing

d. Calcium alginate dressing

Answer: b. Hydrocolloid dressing

Rationale: Hydrocolloid dressings are appropriate for stage 2 pressure

injuries as they provide a moist environment for healing and protect the

wound from contamination.

What is the primary goal of treatment for cellulitis?

a. Pain management

b. Prevention of sepsis

c. Eradication of the causative bacteria

d. Promotion of wound healing

Answer: c. Eradication of the causative bacteria

Rationale: The primary goal of cellulitis treatment is to eliminate the

bacterial infection through appropriate antibiotic therapy.

A patient presents with signs of wound infection. What is the first step in

managing the infected wound?

a. Debridement of necrotic tissue

b. Initiation of broad-spectrum antibiotics

c. Culture and sensitivity testing

d. Application of a sterile dressing

Answer: c. Culture and sensitivity testing

Rationale: The first step in managing an infected wound is to obtain a

wound culture for identification of the infecting organisms and their antibiotic

sensitivities.

Which statement is true regarding the assessment of necrotizing fasciitis?

a. Pain is often disproportionate to the wound appearance

b. Localized erythema is a reliable indicator of infection

c. Subcutaneous emphysema is absent in most cases

d. Wound exploration is unnecessary for diagnosis

Answer: a. Pain is often disproportionate to the wound appearance

Rationale: In necrotizing fasciitis, severe pain is often present and is

disproportionate to the wound's appearance, serving as a key clinical

indicator.

What is a potential complication of untreated IV infiltration?

a. Thrombophlebitis

b. Hypovolemic shock

c. Sepsis

d. Nerve damage

Answer: a. Thrombophlebitis

Rationale: Untreated IV infiltration can lead to inflammation of the vein

(thrombophlebitis) and potentially cause additional complications such as

sepsis or nerve damage.

autonomy - CORRECT ANSWER-the right to make ones own personal decisions, even when those decisions might not be in that persons own best interest beneficence - CORRECT ANSWER-action that is done for the benefit of others fidelity - CORRECT ANSWER-fulfillment of promises justice - CORRECT ANSWER-fairness in care delivery and use of resources nonmaleficence - CORRECT ANSWER-a commitment to do no harm veracity - CORRECT ANSWER-a commitment to tell the truth assault - CORRECT ANSWER-the conduct of one person makes another person fearful and apprehensive battery - CORRECT ANSWER-intentional and wrongful physical contact with a person that involves an injury or offensive contact false imprisonment - CORRECT ANSWER-A person is confined or retained against his/her will negligence - CORRECT ANSWER-careless neglect, often resulting in injury informed consent - CORRECT ANSWER-a legal process by which a client or the clients legally appointed designee has given written permission for a procedure or treatment. Consent is informed when a provider explains and the client understands the reason, the benefits, the risks, and other options. implied consent - CORRECT ANSWER-client adheres to instructions provided by the nurse; ex: the nurse is preparing to administer a TB test and the client holds out his arm for the nurse

advance directive - CORRECT ANSWER-Written documentation that specifies medical treatment for a competent patient should the patient become unable to make decisions; also called a living will or health care directive. living will - CORRECT ANSWER-A document that indicates what medical intervention an individual wants if he or she becomes incapable of expressing those wishes. durable power of attorney - CORRECT ANSWER-a legal agreement that allows an agent or representative of the patient to act on behalf of the patient providers oders - CORRECT ANSWER-the provider must consult the client and the family prior to administering a DNR order or AND (allow natural death) subjective data - CORRECT ANSWER-should document as direct quotes, within quotation marks, or summarize and identify the information as the clients statement. Should be supported by objective data. objective data - CORRECT ANSWER-information that is seen, heard, felt, or smelled by an observer; signs change of shift report - CORRECT ANSWER--given at the conclusion of each shift by the nurse leaving to the nurse assuming responsibility for the client

• can be given face-to-face, audiotaped, or presented during rounds
• should include significant objective info, given in logical order, free of gossip and personal opinions, and relate recent changes in meds, treatments/procedures, or discharge plan telephone reports - CORRECT ANSWER-To document a phone call, the nurse includes when the call was made, who made it (if other than the writer of the information), who was called, to whom information was given, what information was given, and what information was received. telephone or verbal prescriptions - CORRECT ANSWER-best to avoid these, but they are sometimes necessary during emergencies and at unusual times. have a second nurse listen to a telephone prescription, repeat it back, making sure to include the medication's name (spell if necessary), dosage, time, and route. question any prescription that may seem inappropriate for the client. make sure the provider signs the prescription in person within the time frame the facility specifies typically 24 hrs. Transfer (hand-off) reports - CORRECT ANSWER-should include demographic information, medical diagnosis, overview of health status, plan of care, recent progress, any alterations, directives for any assessments or client care within the next few hours, most recent vital signs, meds and last doses, allergies, diet, activity, advance directives, discharge plan, family involvement

incident report - CORRECT ANSWER-A report documenting an incident and the response to the incident; also known as an occurrence report or event report. Five Rights of Delegation - CORRECT ANSWER-right task right circumstance right person right direction/communication right supervision/evaluation Assessment/Data collection - CORRECT ANSWER-Collecting, organizing, documenting, and validating data about a patients health status. Can be obtained from the patient, the family, the physician, diagnostic tests, and information about the patient from other health professionals Analysis/Data Collection - CORRECT ANSWER-use critical thinking skills to identify clients health status or problems, interprets or monitor the collected database, reach an appropriate nursing judgement about the health status and coping mechanisms, and provide direction for nursing care. requires nurses to look at the data and recognize patterns or trends, compare the data with expected standards or reference ranges, arrive at conclusions to guide nursing care. complete and accurate documentation is essential. it should focus on facts and should be highly descriptive. Planning - CORRECT ANSWER-The nurse develops a plan of care that prescribes interventions to attain expected outcomes. The nurse establishes priorities and optimal outcomes of care they can readily measure and evaluate. The nursing care plan is the end product of the planning step. Implementation - CORRECT ANSWER-nurses base the care they provide on assessment data, analyses, and the plan of care they developed in the previous steps. They must use problem-solving, clinical judgement, and critical thinking to select and implement appropriate therapeutic interventions using nursing knowledge, priorities of care, and planned goals or outcomes to promote, maintain, or restore health. Evaluation - CORRECT ANSWER-in nursing process, measuring the effectiveness of the other steps. Determining clients progress. native immunity - CORRECT ANSWER-Restricts entry or immediately responds to a foreign organism through the activation of phagocytic cells, complement, and inflammation passive immunity - CORRECT ANSWER-the short-term immunity that results from the introduction of antibodies from another person or animal. example is breast milk to baby specific adaptive immunity - CORRECT ANSWER-allows the body to make antibodies in response to a foreign organism (antigen), body develops a memory of the infection and can fight it off later

active immunity - CORRECT ANSWER-A form of acquired immunity in which the body produces its own antibodies against disease-causing antigens. Provides permanent immunity. causative agent - CORRECT ANSWER-a pathogenic microorganism that causes disease reservoir - CORRECT ANSWER-human, animal, food, organic matter on inanimate surfaces, water, soil, insects portal of exit - CORRECT ANSWER-any body opening on an infected person that allows pathogens to leave, resp tract (droplet and airborne, TB and pneumonia, gi tract (shigella, salmonella, hep A), genitourinary tract (E.coli, Hep A, HSV, HIV) , skin/ mucous membranes (HSV and varicella) , blood/ body fluids (HIV, Hep B and C) , and transplacental Portal of entry - CORRECT ANSWER-a way for the causative agent to enter a new reservoir or host, can be the same as portal of exit Incubation stage of infection - CORRECT ANSWER-interval between the pathogen entering the body and the presentation of the first symptom Prodromal stage of infection - CORRECT ANSWER-interval from onset of general symptoms to more distinct symptoms. During this time, the pathogen is multiplying Illness stage of infection - CORRECT ANSWER-the interval when symptoms specific to the infection occur convalescent stage of infection - CORRECT ANSWER-patient responds to infection and symptoms decline Iatrogenic infection - CORRECT ANSWER-infection transmitted from a health care worker to a patient common site of HAIs - CORRECT ANSWER-urinary tract and these are often caused by E.coli, staphylococcus aureus, and enterococci serous - CORRECT ANSWER-clear, watery plasma Serous Sanguineous - CORRECT ANSWER-Clear and blood tinged sanguineous - CORRECT ANSWER-bloody drainage purulent - CORRECT ANSWER-containing pus (leukocytes and bacteria)

standard precautions (tier 1) - CORRECT ANSWER--applies to all body fluids (excluding sweat), non-intact skin, and mucous membranes

• hand hygiene recommended after all contact and alcohol-based waterless product is preferred unless hands are visibly dirty; also required after removal of gown
• clean gloves are worn when touching all body fluids, non-intact skin, mucous membranes, and contaminated equipment/articles
• gloves removed and hand hygiene completed between each client
• masks, eye protection, and shields required when splashing or spraying of body fluid may occur
• gloves worn whenever touching anything that has potential to contaminate hands of the nurse
• sturdy, moisture resistant bag used for soiled items; contaminated laundry to be bagged and handled to prevent leaking; equipment for client care properly cleaned and one time use items disposed of
• safety devices on all equipment/supplies enabled after use and sharps disposed of properly
• private room not needed unless client is unable to maintain appropriate hygienic practices transmission precautions (tier 2) - CORRECT ANSWER-1. Airborne

2. Droplet
3. Contact airborne precautions - CORRECT ANSWER-To protect against droplet infections smaller than 5mcg. (measles, varicella, pulmonary or laryngeal tuberculosis) Require:

• a private room
• masks and respiratory protection devices for caregivers and visitors
• negative pressure airflow exchange
• wear full face protection if splashing or spraying is a possibility
• clients should wear a mask if they are outside the room Droplet precautions - CORRECT ANSWER-to protect against droplets larger than 5mcg and travel 3-6 ft from the client (Streptococcal pharyngitis, pneumonia, haemophilus influenzae type b, scarlet fever, rubella, pertussis, mumps, mycoplasma pneumonia, meningococcal pneumonia and sepsis, and pneumonic plague) Require:
• a private room or a room with other clients who have the same disease
• masks for providers and clients
• clients should wear a mask when outside the room Contact precuations - CORRECT ANSWER-To protect against direct client and environmental contact infections ( respiratory syncytial virus, shigella, enteric diseases, wound infections, herpes simplex virus, impetigo, scabies, multidrug resistant organisms, c-dif) antipyretics - CORRECT ANSWER-Drugs that reduce fever

RACE - CORRECT ANSWER-rescue, alarm, contain, extinguish PASS - CORRECT ANSWER-Pull, Aim, Squeeze, Sweep Class A fire extinguisher - CORRECT ANSWER-Used for wood, paper, cloth, and plastic fires, contains pressurized water Class B fire extinguisher - CORRECT ANSWER-Used for flammable liquids and gases such as paint, gasoline, oil, and cooking fats Class C fire extinguisher - CORRECT ANSWER-a fire extinguisher rated to put out electrical fires. ABCDE - CORRECT ANSWER-Airway Breathing Circulation Disability Exposure Semi-fowlers - CORRECT ANSWER- 15 - 45 degrees, typically 30 degrees Fowler's - CORRECT ANSWER-semi-sitting body position in which a person's head and shoulders are elevated 45 to 60 degrees High-fowler's - CORRECT ANSWER- 60 - 90 degrees supine - CORRECT ANSWER-dorsal recumbent, client lies on their back prone - CORRECT ANSWER-lying face down lateral or side-laying position - CORRECT ANSWER--client lies on side with most of weight on the dependent hip and shoulder; arms should be flexed in front of the body; pillow placed under head & neck, the upper arm, and under the leg & thigh to maintain body alignment

• this is a good sleeping position but the client must be turned regularly to prevent development of pressure ulcers on dependent areas; 30 degree lateral position is recommended for clients at risk for pressure ulcers Sims position - CORRECT ANSWER-lying on left side with right knee drawn up and with left arm drawn behind, parallel to the back Position for enemas orthopneic position - CORRECT ANSWER-sitting up and leaning over a table to breathe or tripod position

Trendelenberg position - CORRECT ANSWER-The body is laid flat on the back (supine position) with the feet higher than the head by 15 - 30 degrees, Reverse Trendelenburg's position - CORRECT ANSWER-The head of the bed is raised and the foot of the bed is lowered modified trendelenberg - CORRECT ANSWER-used while trying to promote an increase in venous return - which is measured by BP Used with difficulties with getting blood pressure up and patients who show signs of shock

• The lower extremities are elevated to an angle of about 20 degrees; the knees are straight, the trunk is horizontal, and the head is slightly elevated. triage - CORRECT ANSWER-the medical screening of patients to determine their relative priority of need and the proper place of treatment Emergent or Immediate category (Class I) - CORRECT ANSWER-highest priority is given to patients who have life threatening injuries but also have a high possibility of survival once they are stabilized Urgent or Delayed category (Class II) - CORRECT ANSWER-second-highest priority is given to clients who have major injuries that are not yet life-threatening and can usually wait 30 min to 2 hr for treatment Nonurgent or Minimal category (Class III) - CORRECT ANSWER-the next highest priority is given to clients who have minor injuries that are not life threatening and do not need immediate attention Expectant category (Class IV) - CORRECT ANSWER-the lowest priority is given to clients who are not expected to live and are allowed to die naturally. Comfort measures can be provided, but restorative care is not. digital rectal exam - CORRECT ANSWER-examination of the prostate using a finger inserted into the rectum, during routine physical examination or annually if they have at least a ten year life expectancy colorectal screening - CORRECT ANSWER-FEMALE and MALE: Fecal occult blood test annually starting at age 50; and flexible sigmoidoscopy every 5 years; or colonoscopy every 10 years; or double contrast barium enema every 5 years cervical cancer screening - CORRECT ANSWER-Women 21 - 65 Pap smear with cytology Q3 years Women 30 - 65 Pap smear with HPV testing Q5 years

breast cancer screening - CORRECT ANSWER-The USPSTF recommends screening mammography for women, with or without clinical breast examination, every 1 to 2 years for women age 40 years and older. ages to 20 - 39: clinical breast exam every 3 years, then annually over 55 should have the choice to do a mammogram every 1 - 2 years clinical testicular examination - CORRECT ANSWER-at each routine health care visit starting at age 20, for men, a physical exam of the groin and genitals prostate-specific antigen (PSA) - CORRECT ANSWER-blood test that measures the level of prostate-specific antigen in the blood Primary prevention - CORRECT ANSWER-Efforts to prevent an injury or illness from ever occurring.

• immunization programs
• child car seat education
• nutrition, fitness activities
• health education in schools secondary prevention - CORRECT ANSWER-Efforts to limit the effects of an injury or illness that you cannot completely prevent.
• communicable disease screening, case finding
• early detection, treatment for diabetes mellitus
• exercise programs for older adults who are frail tertiary prevention - CORRECT ANSWER-the stage in preventive stress management designed to heal individual or organizational symptoms of distress and strain
• begins after an injury or illness
• prevention of pressure ulcers after a spinal cord injury
• promoting independence after a TBI
• referrals to support groups
• rehab center infant - CORRECT ANSWER- 2 days old to 1 year toddlers - CORRECT ANSWER- 1 - 3 years Preschoolers - CORRECT ANSWER- 3 - 6 years school age - CORRECT ANSWER- 6 - 12 years adolescence - CORRECT ANSWER- 12 - 20 years young adults - CORRECT ANSWER- 20 - 35 middle adults - CORRECT ANSWER- 35 - 65

older adults - CORRECT ANSWER- 65 and up oral temperature - CORRECT ANSWER-average is 37 degrees C 98.6 degrees F rectal temperature - CORRECT ANSWER-0.5 C (0.9 F) higher than oral Axillary temperature - CORRECT ANSWER-0.5 C (0.9 F) lower than oral and tympanic temporal temperature - CORRECT ANSWER-close to rectal blood pressure cuff - CORRECT ANSWER-should be 40% of the arm circumference at the point where the cuff is wrapped, the bladder should surround 80% of the arm circumference in an adult bronchovesicular - CORRECT ANSWER-over the larger airways vesicular - CORRECT ANSWER-refers to soft, low-pitched, normal breath sounds heard over peripheral lung fields bronchial - CORRECT ANSWER-pertaining to the bronchus, heard over the neck AV valves - CORRECT ANSWER-tricuspid and mitral, hear the S1 sound (lub) semilunar valves - CORRECT ANSWER--aortic valve: prevents back flow into left ventricle

• pulmonary valve: prevents back flow into right ventricle hear the S2 sound (dub) tympany - CORRECT ANSWER-hear this over the abdomen dullness - CORRECT ANSWER-hear this over the liver or a distended bladder light palpation - CORRECT ANSWER-0.5 inch, or 1.3 cm deep palpation - CORRECT ANSWER- 1 - 3 inches, or 2.5-7.5 cm blumberg's sign - CORRECT ANSWER-The experience of sharp, stabbing pain as the compressed area returns to a noncompressed state clubbing - CORRECT ANSWER-bulbous enlargement of distal phalanges of fingers and toes that occurs with chronic cyanotic heart and lung conditions macule - CORRECT ANSWER-examples are freckles or petechiae

papule - CORRECT ANSWER-elevated nevus nodule - CORRECT ANSWER-wart vesicle - CORRECT ANSWER-blister, herpes simplex, varicella pustule - CORRECT ANSWER-elevation of skin containing pus, acne tumor - CORRECT ANSWER-solid mass, epithelioma wheal - CORRECT ANSWER-raised red skin lesion due to interstitial fluid, insect bite stereognosis - CORRECT ANSWER-ability to recognize objects by feeling their form, size, and weight while the eyes are closed graphesia - CORRECT ANSWER-the ability to identify a number drawn on the skin role conflict - CORRECT ANSWER-this develops when a person must assume opposing roles with incompatible expectations. Parents expecting children to participate in sports or a mother who wants to stay home with her infant but is required to work sick role - CORRECT ANSWER-Expectation in society that allows you to take a break from responsibilities. However, if you don't get better or return you are viewed as deviant role ambiguity - CORRECT ANSWER-uncertainty about what the organization expects from the employee in terms of what to do or how to do it role strain - CORRECT ANSWER-the frustration and anxiety that occurs when a person feels inadequate for assuming a role (caregiver burden) role overload - CORRECT ANSWER-more responsibility and roles than are manageable, very common (being a student, athlete, caregiver, employee, or parent at the same time) Buddhism - CORRECT ANSWER-the teaching of Buddha that life is permeated with suffering caused by desire, that suffering ceases when desire ceases, and that enlightenment obtained through right conduct and wisdom and meditation releases one from desire and suffering and rebirth

• brain death might not be considered as a requirement for death
• death is seen as a stage of life
• many prefer death at home
• body is prepared by a male
• preparers avoid touching the body but might touch the head and stand nearby
• many use cremation

Sikhism - CORRECT ANSWER-health care beliefs often correlate with modern medical science- females prefer to be examined by females- having to remove undergarments can be very distressing

• clients might not permit cutting or shaving of their hair
• clients use religious symbols or devotional prayer Navajo - CORRECT ANSWER-view health holistically, wellness interventions instead of disease prevention, clients may attempt to correct poor health using symbols, songs, rituals, prayers, and paintings (blessingway) Hinduism - CORRECT ANSWER-illness can be a cause of past sins, decisions may be made by senior family, females defer to a spouse or family to make decisions, might decline porcine-derived medications
• some may be vegetarian
• clients may want to lie on the floor when dying, or the body may be placed on the floor
• clients prepare for death with prayer and meditations
• care by those of the same gender
• cremation (Purify) Islam - CORRECT ANSWER-clients may avoid conversations about death, believe it is predetermined, may permit withdrawal of life saving measures, avoid euthanasia and organ transplantation, may decline porcine derived medications, avoid alcohol and pork, may fast during Ramadan,
• body may be wrapped in cloth by someone of the same gender
• face turned to Mecca (east southeast)
• prayer is said
• burial is preferred
• five pillars of islam, group prayer, prayer five times a day Jehovahs witness - CORRECT ANSWER-might not accept blood transfusions, may avoid foods with blood or prepared with blood, burial or cremation Judaism - CORRECT ANSWER-balance between God and medicine, might refuse treatment on the Sabbath, feel an obligation to visit the ill, life supporting measures are discouraged, 8th day after birth males are circumsized, some may practice a kosher diet
• someone often stays with the body
• dont typically permit autopsy
• burial occurs usually within 24 hrs.
• cremation or embalming are not usually permitted Kubler-Ross stages of grief - CORRECT ANSWER-1. Denial

2. Anger
3. Bargaining
4. Depression
5. Acceptance

BMI calculation - CORRECT ANSWER-weight (kg) / height (m^2) normal BMI is 25 Cane Instructions - CORRECT ANSWER--Maintain two points of support on the ground at all times.

• Keep the cane on the stronger side of the body.
• Support body weight on both legs, move the cane forward 6 to 10 inches, then move the weaker leg forward toward the cane.
• Next, advance the stronger leg past the cane Crutch Instructions - CORRECT ANSWER--Do not alter crutches after fitting.
• Follow the prescribed crutch gait.
• Support body weight at the hand grips with the elbows flexed at 30°.
• Position the crutches on the unaffected side when sitting or rising from a chair.
• 6 in. in front of and 66 in. on either side acute pain - CORRECT ANSWER-episode of pain that lasts from seconds to less than 6 months idiopathic pain - CORRECT ANSWER-chronic pain in the absence of an identifiable physical or psychological cause or pain perceived as excessive for the extent of an organic pathological condition chronic pain - CORRECT ANSWER-episode of pain that lasts for 6 months or longer; may be intermittent or continuous nociceptive pain - CORRECT ANSWER-normal process that results in noxious stimuli being perceived as painful. types of nociceptive pain are somatic, visceral, and cutaneous neuropathic pain - CORRECT ANSWER-abnormal processing of pain message; burning, shooting in nature, pins and needles aloe - CORRECT ANSWER-wound healing chamomile - CORRECT ANSWER-anti-inflammatory, calming echinacea - CORRECT ANSWER-stimulates immune system garlic - CORRECT ANSWER-inhibits platelet aggregation, interacts with warfarin and blood thinners