NOTE: Remember NR 224 requires you to answer exam questions in which you will have to not only
understand but also apply information related to the concepts covered in the course. The intent of this
study tool is to outline the major content that will be covered on the exam. Additional content may be
included on the exam.
Critical Thinking What are principles related to HIPAA?
Be prepared to prioritize and to consider the • Patients’ privacy, who the patient
best option when answering exam give right to have his information
questions. • Patient information can be used or
disclosed by a health plan, provider
What considerations are important when • HIPAA enables patients to find out
determining the best option? how their information may be used
and how it has been disclosed
Whatever decision is best for the patient
• gives patients the right to examine
and obtain a copy of their own health
When should the nurse delegate vs not records and to request corrections.
delegate? What is HIPAA?
Delegation: “transferring responsibility for a • Health Insurance Portability and
performance of an activity or task while Accountability Act
retaining accountability for an outcome” • Focuses on Patient Health
Information
• assigning tasks to other healthcare • Stipulates how healthcare workers
professionals (vitals, labs); UAP can share information
(unlicensed assistive personnel), A major component of the Health Insurance
LPNs Portability and Accountability Act (HIPAA),
the Privacy Rule, was introduced to promote
Not delegate: “to do on your own or not the use of standard methods of maintaining
share the tasks” the privacy of protected health information
(PHI) among health care agencies.
• give meds, change in status, receive
new meds, new admission, teaching
Nursing Process
Review the steps in the nursing process. Be
What are essential steps the nurse should do prepared to interpret a scenario/situation to
prior to performing any skill on a patient? determine the corresponding step in the
-AIDET nursing process.
A-Acknowledge (greet the patient) • Assessment: gather all subjective
I- Introduce yourself and objective data
D- duration of assessment • Diagnosis: NANDA, nursing
diagnosis for actual problems,
E- explain the procedure
T- thank you Potential problems, or risk for
-Hand hygiene and provide privacy problems.
• Outcome identification:
-Identify your patient using name and DOB SMART goals for pt (patient)
-Assess allergies • Planning: nurse/pt make a plan to
-Assess pain achieve the goal
-Determine level of consciousness (LOC)
ACR/
, NR 224 Final Exam Key Concepts
• Implementation: how the nurse
will put the plan into action & peripheral IV catheters or a central
Interventions intravenous line.
• Evaluation: was the goal met and 2. when the integrity of the skin is
what needs to be adjusted broken as a result of trauma,
surgical incision, or burns
3. during procedures that involves
Consider nursing diagnoses that are invasive procedures such as insertion
applicable to a given situation/scenario. of a urinary catheter or surgical
instruments into sterile body cavities
such as insertion of a wound drain
Infection Prevention and Control List strategies/interventions that may
What is the difference between clean prevent infection transmission.
(aseptic) and sterile technique? • Standard precaution (wash hands,
gloves) => apply when contact with
• Clean is the routine hand hygiene, blood, body fluid, non-intact skin,
drying and use of nonsterile gloves, and mucous membrane.
it uses for taking blood, examining
patients, and feeding patients. • Hand hygiene is the most
effective basic technique in
• Sterile techniques used for preventing and controlling the
surgery and invasive procedures transmission of infection.
with high rates of infection. It
involves What are principles associated with creating
surgical hand rub with long and maintaining a sterile field?
actin antiseptic, dry hands with consider the 2.5cm (1 inch) around the
sterile towel, sterile field (gown, sterile gloving contaminated
mask, gloves, supplies), skin must be waist level
prep, a dedicated room.
What is PPE?
• While clean means free from marks PPE: Personal protective equipment for
and stains, sterile goes even further protection against exposure to infectious
and is free from bacteria or materials. This includes gloves, mask,
microorganisms goggles, hair net and gown.
Removal: gloves comes off first, then gown,
• Sterile: No SPORES or mask, head pieces, and first thing that goes
microorganisms on
Standard precautions: handwashing
What are examples of skills and procedures What are the different types of isolation
that should be performed using clean precautions and considerations are
technique? Sterile technique? associated with each type?
1. During procedures that require • Standard precautions should be used
intentional perforation of the in all settings and it includes hand
patient’s skin, such as insertion washing, when hands are visibly
of soiled used antibacterial soap and
water, when not visibly soiled use hand
ACR/
, NR 224 Final Exam Key Concepts
sanitizer or hand rub and it must be Remove gloves, eyewear, gown, then mask
60% and above alcohol
• Airborne - smaller than 5 microns. (top first then bottom), Removing = Gloves,
Negative air pressure, 6-12 exchanges eyewear, gown and mask.
using HEPA filter, N95 respirator, mask,
private room. Measles, Tuberculosis Why? gloves could be visibly or non-visibly
and soiled, so get rid of it first, then eye wear or
Varicella (chicken pox)(MTV) goggles, gown to avoid the contaminants
from spreading then mask
• droplets - larger than 5 microns.
private room or cohort, mask or
respirator Sterile field
• contact - must have gloves and gown, ● Sterile object remains sterile if
private room or cohort patients. touched by another sterile object
• PPE - positive air pressure, private ● Only objects that are sterile must be
room, 12 and above air exchanges placed on a sterile field
using HEPA filter, mask worn by the ● Sterile object is assumed
patients
Type Infection Barrier PPE contaminated if it is out of field of
Airborne Measles Private room with Mask vision or below the waist
door closed
(small Varicella (chicken Negative pressure
Respiratory ● A sterile object of field becomes
droplets) pox) airflow (6-12) protection
<5 microns exchanges by device contaminated by prolonged exposure
TB HEPA filter
Air is not filtered
N95 worn to air. It becomes contaminated with
inside room but by health
by HEPA care
in time
workers ● Sterile surface come in contact with
gloves wet surface it becomes contaminated
Droplet Diphtheria Rubella Private Surgical
>5
Mumps
room or Mask by capillary action
Streptococcal pharyngitis
microns Pneumonia cohort (within 3 ● Fluid flows in the direction of
< 3 feet Influenza feet of gravity
Meningitis
patient)
Hand
● The edges of a sterile field or
hygiene container are considered
(after) contaminated
Respirator
○ (Think of the edges when
Contact VRE (Vancomycin Private Gloves opening the sterile gloves in
Resistant Enterococci)
MRSA
room or Gown lab)
C. Diff cohort
Herpes simplex Vital Signs
Varicella zoster
What are the normal ranges associated with
Protective Allogeneic Private room Mask worn each vital sign?
hematopoietic stem Positive by patient ● Temperature (normal):
cell transplant airflow (>12) thermometer (15 min drink/smoke)
Immunocompromise HEPA filter
d
○ Body: 36-38 C/ 96.8-100.4 F
○ Oral: 37 C
○ Rectal: 37.5 C (red probe)
What item should be removed first? ○ Axillary: 36.5 C
Why?
ACR/
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