ASEPSIS 1
What does each letter of REEDA wound assessment mean
What is...
R - redness
E - edema
E - ecchymosis
D- drainage
A - approximation
(Slide 6 of ASEPSIS FALL 2025 POWER POINT BY MRS KLETTKE)
Normal RANGE for WBC
What is...
5,000-10,000
(slide 14 of ASEPSIS FALL 2025 POWER POINT BY MRS KLETTKE)
Why do foreign microorganisms need nutrients and oxygen?
What is...
To grow, multiply, and live.
(Slide 11 of ASEPSIS FALL 2025 POWER POINT BY MRS KLETTKE)
A "chart" is a form a ____ document that protects both the providers and the institution.
What is...
Legal document
(Slide 5 of documentation FALL 2025)
Poor charting can be seen as _______.
(NOT lAIYNESS)
What is...
Careless
What is...
S- situation "Here's the situation."
B - Background - pertinent pt. information.
A - Assessment - your assessment of the situation
R - Recommendation
(Slide 34 of documentation FALL 2025)
What are the 5 types of drainage and what do they look like
What is...
1. Serous - clear / straw in color, water-like consistency
2. Sanguineous - bloody
3. Serosanguineous - a combo of serous and sanguineous pink/light red water-like consistency
What is...
Warm, dark, and moist
(slide 11 of ASEPSIS FALL 2025 POWER POINT BY MRS KLETTKE)
A nurse wipes off a patient's bedside table, the nurse is demonstrating ____ _____.
What is...
Medical asepsis
(Slide 48 of ASEPSIS FALL 2025 POWER POINT BY MRS KLETTKE)
The nurse opens the patient's chart and finds a list of 'patient problems' that she can click on in order to document findings about a specific problem. This type of EMR organization is known as
What is...
problem-oriented organization
(slide 7 of documentation FALL 2025)
If a nurse is running behind on charting and a late entry is made the nurse should
What is...
Leave a note clarifying that the entry made was a late entry
(NUR 111 packet page unit V -5 )
What is the advantage of a source-oriented EMR organization
What is...
Easy to locate the care provided by each discipline, easier to locate labs/test results
The difference between a contaminated wound and an infected wound
What is...
Contaminated wounds have microorganisms present, but there will be no signs of infection, while infected wounds have microorganisms present and cause harm by releasing toxins, with s/s of local infection
(slide 5 of ASEPSIS FALL 2025 POWER POINT BY MRS KLETTKE)
5 S/s of LOCAL infection
What is...
1. Redness (Erythema) - from increased blood flow
2. Heat - from vasodilatation
3. Edema - accumulation of fluid
4. Pain - likely from swelling
5. Drainage - as a product of infection
(slide 15 of ASEPSIS FALL 2025 POWER POINT BY MRS KLETTKE)
IMPAIRED SKIN INTEGRITY should be used when referring to stage __ and __ pressure ulcers and partial thickness wounds, while IMPAIRED TISSUE INTEGRITY should be used when referring to stage __ + ___ pressure ulcers and full thickness wounds.
What is...
Skin = stages 1+2
Tissue = stages 3+4
(slide 52 of ASEPSIS FALL 2025 POWER POINT BY MRS KLETTKE)
The type of EMR organization where each discipline documents separately is known as
What is...
Source-oriented organization
(slide 7 of documentation FALL 2025)
If a mistake is made on a paper chart, the nurse must
What is...
Put a line through the mistake and write their initials near it so that information may be omitted from the chart.
The nurse has completed her assessment, planned her pt. goals/ outcomes and interventions, and implemented her interventions. What is the final step in the nursing process that the nurse must complete?
What is...
EVALUATION of interventions and goals
(Slide 13 of documentation FALL 2025)
The goal of MEDICAL asepsis is to...
What is...
reduce the number of pathogens
(slide 38 of ASEPSIS FALL 2025 POWER POINT BY MRS KLETTKE)
What is...
Eliminate all pathogens
(slide 38 of ASEPSIS FALL 2025 POWER POINT BY MRS KLETTKE)
Difference between an infected wound and colonized wound
What is...
Microorganisms are present in both, but in infected wounds, they cause harm by releasing toxins, and s/s of local infection will be present.
While in colonized wounds, microorganisms are carried by hr body, but not enough to cause harm.
(Slide 5 of ASEPSIS FALL 2025 POWER POINT BY MRS KLETTKE)
A nurse begins working at a new hospital and is learning the EMR system. The nurse notices that only significant findings or exceptions that differ from 'normal' are charted, the nurse should recognize this charting technique is called...
What is...
Charting by exception
(slide 9 of documentation FALL 2025)
A nurse notices a change in the patient's status and secure chats the provider via the EMR system to notify the provider of the change in status and ask for further instruction. After messaging the provider, it is important that the nurse does what in relation to documentation
What is...
Chart "provider notifed."
(NUR 111 packet pg. unit V - 6)
True or false
Your nurse friend helps you by passing medication for Mr. Johnson even though it's your patient. You are still responsible for documenting the medication administered.
What is...
FALSE, document only the interventions YOU performed. NEVER document the interventions done by someone else, even if it's your patient.
List the 10 general s/s and symptoms of systemic (body-wide) infection
What is...
1. fever greater than 101
2. Chills and sweat
3. Malaise (general feeling of unwell or discomfort)
4. Fatigue
5. Anorexia
6. Muscle aches
7. Diaphorsesis
8. irrirability
9. headache
10. Elevated WBC
(slide 14 of ASEPSIS FALL 2025 POWER POINT BY MRS KLETTKE)
A pressure ulcer that heals from the inner layer by filling in with beefy red granulation tissue, healing slowly and leaving a scar, is which type of wound healing intention
A) Primary intention
B) Secondary intention
C) Tertiary intention)
What is...
Secondary Intention
(slide 52 of ASEPSIS FALL 2025 POWER POINT BY MRS KLETTKE)
A nurse preceptor is walking her student through the process of collecting a wound culture. What action by the student nurse should indicate to the preceptor that further education on wound culture collection is necessary?
A) The student nurse swabs only clean, granulating tissue
B) The student nurse avoids wound edges
C) The student nurse cleans and irrigates the wound only after obtaining the specimen
D) The student nurse swabs only a 1 cm x 1 cm area
What is...
C) The student nurse cleans and irrigates the wound only after obtaining the specimen
THIS SHOULD BE DONE FIRST. Cleaning and irrigating the wound is the first step, so that old drainage and other contaminants not native to the wound can be washed away
(Slide 56 of ASEPSIS FALL 2025 POWER POINT BY MRS KLETTKE)
PATIENT CONFIDENTIALITY IS OF SPECIFIC CONCERN WITH WHICH TYPE OF DOCUMENTATION? Select All.
A)Source-oriented medical record
B)Problem-oriented medical record
C)Charting by exception
D)Computerized charting (EHR)
What is...
D) Computerized charting (EHR) due to the risk of passwords being shared, meaning someone who is not the nurse logged in can document under that nurse's name
(Slide 11 of documentation FALL 2025)
TRUE OR FALSE
Spiritual concerns should be documented
What is...
TRUE - spiritual concerns/beliefs may cause the patient to deny certain medical treatments
(Slide 17 of documentation FALL 2025)
What does HIPAA stand for, and WHAT does it protect
What is...
Health Information Portability and Accountability Act,
It protects the patient and their Private Health Information (PHI)