Review Day Presentation- Group 1

Nursing Process, CJ Model, Safety & Infection Control

Multiple Choice

What is ADPIE?

• Assessment, Documentation, Predict, Intervention, End

• Assessment, Diagnosis, Planning, Implementation, Evaluation

• Asystole, Documentation, Planning, Ideation, Evaluation

• Absorption, Diagnosis, Prediction, Intervention, End

The acronym ADPIE stands for:


Asessment
Diagnosis
Planning
Implementation
Evaluation




ADPIE is a framework that helps to make decisions and provide exceptional patient care.

Multiple Choice

Which of the following is NOT an example of a nursing diagnosis

• Ineffective Airway Clearance

• Impaired Urinary Elimination

• Cerebrovascular Accident

• Risk of Infection

​Nursing Diagnosis vs Medical Diagnosis

A nursing diagnosis is a judgement and observation obtained by the nurse; it is not a proper medical diagnosis. Ineffective airway clearance, impaired urinary elimination, and risk of infection are all observations and judgements made by a nurse. A medical diagnosis such as a cerebrovascular accident would need to be diagnosed by a physician rather than a nurse.

Multiple Choice

A student nurse is constructing SMART goals for a post-op patient. Which of the following demonstrates the student nurse understands how to effectively create SMART goals?

• The patient will be able to ambulate 10 feet, five times a day, with minimal assistance within one day post-op

• The patient will report improved pain from a 10/10 to a 4/10 after hip replacement surgery

• The patient will understand triggers for anxiety after teaching from the nurse

• The patient will be able to ambulate 5 feet everyday

A SMART goal stands for:


Specific
Measurable
Achievable
Realistic
Timely

​SMART goals must be specific, measurable, achievable, relevant and be time specific. The only answer demonstrating a goal that meets each of these requirements is answer choice. Answer choice B is lacking a time. Answer C is lacking aspects that are specific and time sensitive. Answer choice D is lacking specifics and a time.

Multiple Select

Which of the following are components of Tanner's CJM? Select all that apply.

• Noticing

• Responding

• Understanding

• Interpreting

• Reflecting

​ Tanners' Clinical Judgement Model (CJM)

Tanners' clinical judgement model helps to encourage the process of thinking and analyzing. The components of this model include noticing, interpreting, responding and reflecting. Tanners' Clinical Judgment Model is a conceptual framework that guides nurses through the information gathering, assessment, and analysis processes that lead to effective decision-making

Multiple Choice

A student nurse is performing a sterile procedure. Which of the following would indicate a need for further teaching?

• The student opens the sterile packages away from their body

• The student avoids touching the outer one inch of the sterile field

• The student keeps their arms above waist level the entire procedure

• The student turns around to see who came into the room in order to protect the patient's privacy

​Sterile Technique

​Answer choice D indicates the student needs further teaching. You should never turn your back on a sterile field in the instance that the field could become contaminated.

Multiple Choice

A nurse is caring for a client with Clostridioides Difficle (C. Diff). Which of the following infection control measures is the most appropriate?

• Using alcohol-based hand sanitizer before and after patient contact

• Placing the client in a negative pressure room

• Wearing gloves and a gown when entering the patient room

• Administer prophylactic antibiotics to visitors

​Contact Precautions/Isolation

Wearing a gown and gloves is the only effective way to help prevent the spread of the spores that C. Diff contains. Alcohol based products are not effective against C. Diff spores

Multiple Choice

During assessment of an IV, the nurse notes erythema, warmth, and swelling at the site. Which of the following is the most appropriate nursing action?

• Remove the IV catheter and notify the provider

• Document the findings and continue monitoring

• Flush the IV with normal saline

• Apply an ice pack to the site

Erythema, warmth and swelling at an IV site could be indicative of phlebitis, infiltration or extravasation. Removing the intravenous line is necessary to prevent further complications and the spread of the infection.

Multiple Choice

A nurse is preparing to change a surgical wound dressing. Which action by the nurse best demonstrates correct infection control practices during the dressing change?

• Cleaning the wound with an aseptic solution, starting from the most soiled area to the least soiled area

• Removing the old dressing with clean gloves and applying a new sterile dressing using sterile gloves

• Applying a new sterile dressing with clean gloves after removing the old dressing

• Flushing the wound with normal saline before applying a new sterile dressing, using clean gloves throughout the process

​The nurse should use clean gloves to remove the old dressing, and sterile gloves to apply the new sterile dressing to maintain a sterile field and minimize the risk of infection to the surgical wound. You should always clean from the least soiled area to the most soiled area.

Multiple Choice

After 3 days of antibiotic therapy, a client's surgical site appears less red and swollen. Which nursing action is most appropriate?

• Discontinue the antibiotics

• Notify the provider of suspected resistance

• Document the findings as improvement

• Increase the dose of the antibiotic

​It is important to ensure the patient finishes the complete round of antibiotics to prevent antibiotic resistance. It is not appropriate to increase the dose antibiotic. The surgical site being less red and swollen indicates that the antibiotic is effective.

Multiple Select

When caring for a patient on droplet precautions, which personal protective equipment should the nurse wear?

• N95 respirator

• Eye protection

• Surgical mask

• Gloves

• Gown

​Droplet Precautions

​Droplet precautions are used for infections that are transmitted by respiratory droplets during coughing, sneezing, or procedures like suctioning. Surgical masks protect the nose and mouth from droplets. Eye protection like goggles or face shields prevent exposure to the mucous membranes. An N95 respirator is indicated for airborne precautions rather than droplet.

Multiple Choice

When providing patient care, which is the best way to prevent the spread of infection through hand hygiene?

• Wear gloves at all times to avoid the need for handwashing

• Use hand sanitizer before and after patient contact

• Apply hand lotion after washing hands to maintain moisture

• Wash hands with soap and water before and after patient contact

Hand sanitizer should only be used between handwashes but should not replace handwashing. Wearing gloves is a good way to prevent the transmission of infections, but only when necessary. Washing hands with soap and water before and after patient contact is best practice to prevent the spread of infection.

Multiple Select

When obtaining a mid-stream urine specimen, the nurse should...?

• Put on clean gloves before opening the kit

• Write the patients name on the inside of the lid of the specimen cup

• Instruct the patient to void a small amount into the toilet, then collect the specimen in the cup

• Instruct the patient to cleanse the peri area with antibacterial towelette

• Leave the urine sample for 24 hours to mature before sending it to the lab

​Mid-Stream Urine Specimen Collection

​The nurse SHOULD:
- instruct the patient to cleanse peri area
- put on clean gloves
- instruct the patient to collect mid- stream
- send the urine sample directly to the lab



The nurse SHOULD NOT:
- touch the inside of the specimen cup

Multiple Choice

A patient with active tuberculosis is admitted to the hospital. Which room placement is indicated for this patient?

• Semi-private room with contact precautions

• Any available room with droplet precautions

• Open unit with standard precautions

• Private room with negative air pressure

​A private room with negative air pressure is the most appropriate for this patient. Tuberculosis is an airborne disease transmitted through droplets. Negative pressure isolates the contaminated air and prevents it from circulating to other areas of the facility

​Negative Air Pressure- Tuberculosis

Multiple Choice

A patient arrives at the clinic with signs of an upper respiratory infection. Which type or transmission-based precautions should the nurse implement?

• Contact precautions

• Droplet precautions

• Airborne precautions

• Standard precautions

​Upper respiratory infections like influenza are transmitted through large respiratory droplets generated by coughing and sneezing. Droplet precautions are the most appropriate precautions to implement.