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HESI Patient Review: Dave Mason You question Dave regarding his immunization status. Your initial concern is determining his potential susceptibility to infection. Hint A. staphylococcus B. tetan... us C. hepatitis D. streptococcus Your time with Dave has been brief, but you are able to set priorities for his care. Which of the following is pertinent and most important for Dave's care at this time? Hint A. Impaired Physical Mobility related to injured left thigh B. Fear related to potentially-serious injury to left thigh C. Risk for Infection related to loss of protective skin barrier at injured left thigh D. Ineffective Peripheral Tissue Perfusion related to left thigh inflammation In caring for Dave, your primary nursing goal is to: Hint A. prevent infection of Dave's wound B. prevent the transmission of microbes from Dave's wound to other persons C. alleviate Dave's fears about his wound D. cleanse and dress Dave's wound utilizing principles of asepsis You use Standard Precautions while working with Dave. Standard Precautions are used with Dave because: A. it is likely that his wound is contaminated B. it is likely that his wound is colonized with a highly-transmissible pathogen C. he is at risk for infection D. Standard Precautions are indicated with all patients You prepare to care for Dave's wound, by carrying out the most important activity for preventing the transmission of microorganisms, which is: A. handwashing B. wearing clean, non-sterile glovesC. wearing sterile gloves D. setting up a sterile field Which of the following apply to proper routine handwashing technique? Select all that apply (there are 3 correct answers). A. Hands should be washed for 10-15 seconds B. Handwashing destroys all microorganisms on the hands C. Friction should be used when hands are washed D. Rings should be removed for handwashing You have gathered supplies to clean Dave's wound. Which of the following are indicated for cleansing Dave's wounds? Select all that apply (there are 2 correct answers). Hint A. Gloves should be worn B. A face shield and gown should be used C. Any open areas should be cleansed from the outer to the inner aspects D. The wounds should be scrubbed with a brush Sterile normal saline is appropriate for flushing Dave's wounds because it should: Select all that apply (there are 2 correct answers). Hint A. destroy any bacteria that might be present B. not damage cells required for tissue repair C. clear away any surface debris D. neutralize any bacterial toxins that are present E. promote an isotonic environment Which of Dave’s wounds has greatest risk for infection? A. The laceration B. The scratches C. The puncture wounds Your protective clothing is removed when you are done cleaning Dave's wounds. To prevent selfcontamination when protective clothing is removed, the clothing is removed in which order? A. Remove gloves, remove face shield, undo gown neck, undo gown waist, remove gown B. Undo gown waist, undo gown neck, remove gown, remove face shield, remove gloves C. Undo gown waist, undo gown neck strings, remove gown, remove gloves, remove faceshieldDave asks about the solution that the physician used to clean his wounds, povidone-iodine (Betadine), and why it's used. Which response is best? Hint A. "Betadine is an antiseptic solution that helps to destroy bacteria in a wound." B. "Betadine solution destroys bacteria and eliminates dirt from a wound by acting as anoxidizing agent." C. "I'll have the physician tell you about it later." D. "We always use Betadine solution to treat wounds like yours." Signs and symptoms of normal inflammation are expected at Dave's wound sites over the next few days. These include: Select all that apply (there are 4 correct answers). Hint A. purulent drainage B. edema C. necrosis D. erythema E. tenderness F. atrophy G. warmth The Td booster Dave receives will provide what kind of immunity? Hint A. Naturally-acquired active immunity B. Artificially-acquired active immunity C. Naturally-acquired passive immunity D. Artificially-acquired passive immunity Which of the following instructions are appropriate for Dave? Select all that apply (there are 3 correct answers). Hint A. Wash hands before caring for wounds B. Touch only the inner parts of dressing material C. Wash hands after caring for woundsD. Gently cleanse away any debris You teach Dave that he can make his own wound-cleansing solution at home. A possibility is: A. mixing 1 cup of vinegar in 1 quart of hot tap water B. mixing 2 tablespoons of bleach in 1 quart of hot tap water C. mixing 2 teaspoons of salt in 4 cups of boiled tap water Dave asks what he can do to alleviate the throbbing pain he feels at the wound site. Which of the following should help? Select all that apply (there are 3 correct answers). Hint A. A dry cold compress placed over the dressed wound area for today B. A moist warm compress placed over the dressed wound as needed for today C. Acetaminophen by mouth every four hours as needed D. Leg elevation Dave is also taught about signs and symptoms of infection to watch for and report. These include: Select all that apply (there are 4 correct answers). Hint A. decreasing wound size B. increasing redness and swelling at a wound site C. green or yellow drainage from a wound site D. odor coming from a wound site E. an elevated body temperature To evaluate the effectiveness of your teaching with Dave, which of the following would be best? Hint A. Have Dave describe the dressing technique he will use B. Have Dave demonstrate the dressing technique he will use Unfortunately, an isolation room is not available for Dave. He will need to be in a 4-bed room. Of the patient mix below, which is best for Dave? Hint A. Two preoperative patients (cholecystectomy, appendectomy), and a patient taking steroidsB. Three oncology patients receiving chemotherapy C. Three postoperative patients (total hip replacement, total colectomy, laparoscopic cholecystectomy) D. Three patients with medical conditions (peptic ulcer disease, diverticulitis, back pain) After reviewing Dave's orders, which of the following should you implement first? Hint A. Administer the first dose of Timentin B. Order Dave a meal tray C. Irrigate and dress Dave's wound as ordered D. Take the wound and blood cultures Of the techniques shown below, which are appropriate when culturing Dave's left thigh wound? Select all that apply (there are 2 correct answers). Hint A. Thoroughly rinse wound with sterile saline prior to culturing B. Be sure to culture any purulent drainage C. Obtain separate cultures for different areas of the laceration D. Rotate culture swab within the wound from edge to edge After culturing Dave's wound, you proceed to take the blood cultures that are ordered. Which of the following describes correct technique? A. Draw the specimens through Dave's IV catheter, at 15-minute intervals B. Draw the specimens from a venipuncture site separate from the IV site, at 15-minuteintervals C. Draw the specimens from two venipuncture sites separate from the IV site When taking the blood cultures, you correctly: Select all that apply (there are 3 correct answers). A. wear gloves B. cleanse the venipuncture sites with an antiseptic C. cleanse the tops of culture tubes/bottles with an antiseptic D. shake the specimen tubes/bottles well after collecting the specimens E. place the specimens on ice and have them immediately transported to the laboratory A hospital-acquired infection is also called a/an infection.A. cyptogenic B. nosocomial C. opportunistic Which of the following approaches is BEST if you are in doubt as to whether or not gloves should be worn for patient contact? Hint A. Do not wear gloves but determine proper procedure for next time B. Wear gloves and clarify proper procedure for next time C. Ask the patient his diagnosis before deciding if gloves are necessary D. Ask the physician to prescribe if gloves are to be worn You proceed with Dave's wound care using surgical asepsis. You set up a sterile field, placing all required sterile supplies on the field. Inadvertently, some sterile saline moistens the center of the sterile field. What should you do? Hint A. Consider the moistened, central area of the sterile field contaminated and work in the outer aspects of the field B. Obtain and set up a new sterile field with new sterile supplies C. Proceed with the use of the entire sterile field since it was moistened with a sterile solution After irrigating Dave's wound, you proceed with loosely packing the laceration with saline-moist 100% cotton gauze. The moist saline gauze is intended to: Select all that apply (there are 4 correct answers). A. protect the wound from trauma B. absorb exudate C. accomplish debridement D. fill dead space in the wound E. maintain a moist wound bed According to guidelines established by the Centers for Disease Control (CDC), in addition to Standard Precautions, what precautions should be followed for Dave? Hint A. Airborne B. ContactC. Reverse D. Droplet Which of the following isolation protocols are indicated for Dave's care? Select all that apply (there are 2 correct answers). A. A mask should be used when working with Dave B. Gloves should be used while providing direct care C. A sterile gown is required for wound care procedures D. A clean gown is required when clothing may come in contact with Dave or any of hisbody secretions You know that acetaminophen should be effective in reducing Dave's temperature because of its action. A. antipyretic B. anti-inflammatory C. analgesic D. antiinfective Dave has many friends, and flowers and potted plants are at his bedside. One of the flower arrangements needs water. Which of the following is preferable? A. Wearing gloves, add water to the flower arrangement, then wash your hands B. Add water to the flower arrangement, being sure to wash your hands afterwards C. Ask a staff person who does not provide patient care to take care of adding water to theflower arrangement [Show More]

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