Clinical Nursing Skill Ch 10

6. Which patient may the nurse suspect will be at risk for a latex allergy? a. Patient with food allergies b. Patient with diabetes c. Patient with arthritis d. Patient with hypertension

ANS: A Individuals at risk for latex allergy include those with a history of food allergies. Patients with diabetes, arthritis, and hypertension are not at increased risk for latex allergies. DIF: Cognitive Level: Application REF: Text reference: p. 266 OBJ: Identify individuals at risk for latex allergy. TOP: Latex Allergy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

3. When removing the mask after an aseptic procedure, what should the nurse do first? a. Remove gloves. b. Untie top strings of mask. c. Untie bottom strings of mask. d. Untie top strings and let mask hang.

ANS: A Remove gloves first, if worn. This prevents contamination of hair, neck, and facial area by contaminants on gloves. Untie the top strings of the mask after untying the bottom strings. This prevents the top part of the mask from falling down over the clothing. If the mask falls and touches the clothing, it will be contaminated. DIF: Cognitive Level: Application REF: Text reference: p. 259 OBJ: Apply and remove a cap, mask, and eyewear correctly. TOP: Removing the Mask KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

3. A sterile field consists of which of the following? (Select all that apply.) a. Sterile tray b. Work surface draped with a sterile towel c. Table covered by a large sterile drape d. Patient's bedside table

ANS: A, B, C A sterile field may consist of a sterile kit or tray, a work surface draped with a sterile towel or wrapper, or a table covered with a large sterile drape. A patient's bedside table is not sterile but can be a work surface where a sterile field can be applied. DIF: Cognitive Level: Application REF: Text reference: p. 261 OBJ: Perform the following skills: applying sterile gloves using open glove method, preparing a sterile field, applying a sterile drape correctly. TOP: Sterile Field KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE 1. Nurses commonly use surgical asepsis in which of the following situations? (Select all that apply.) a. In labor and delivery areas b. When inserting an intravenous catheter c. When treating patients with surgical incisions or burns d. When inserting a urinary catheter e. When dressing an MRSA-positive wound

ANS: A, B, C, D Although nurses commonly practice surgical asepsis in operating rooms, labor and delivery areas, and major diagnostic or special procedure areas, they use surgical aseptic techniques at the patient's bedside in three primary situations: (1) during procedures that require intentional perforation of a patient's skin (e.g., insertion of intravenous [IV] catheters), (2) when the skin's integrity is broken as the result of a surgical incision or burns, and (3) during procedures that involve insertion of devices or surgical instruments into normally sterile body cavities (e.g., insertion of a urinary catheter). Dressing an MRSA-positive wound is not one of the three primary situations that impact skin integrity. DIF: Cognitive Level: Application REF: Text reference: p. 257 OBJ: Discuss settings in which you will use surgical aseptic techniques. TOP: Surgical Asepsis KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity

2. The patient has just had a tracheostomy tube placed and is expectorating copious amounts of sputum that he coughs forcefully from his tracheostomy tube. The patient also is suspected of having methicillin-resistant Staphylococcus aureus (MRSA) in his sputum. The nurse is preparing to suction the patient to clear his airway. Which of the following will the nurse need to wear if following standard precautions? (Select all that apply.) a. Mask b. Goggles c. Gown d. Sterile gloves

ANS: A, B, C, D Standard precautions are used for potential contact with blood and all body fluids. The use of standard precautions calls for the wearing of masks in combination with eye protection devices such as goggles or glasses with solid side shields whenever splashes, spray, splatter, or droplets of blood or other potentially infectious fluids may occur. These barriers keep the eyes, nose, and mouth free from exposure. Similarly, you wear gowns when there is risk of being splattered with blood or other infectious materials. All health care institutions need to provide to all employees at risk for exposure personal protective equipment and instructions for its use. DIF: Cognitive Level: Synthesis REF: Text reference: p. 257 OBJ: Identify principles of surgical asepsis. TOP: Standard Precautions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

5. A patient requires a sterile dressing change for a mid-abdominal surgical incision. An appropriate intervention for the nurse to implement in maintaining sterile asepsis is to: a. put sterile gloves on before opening sterile packages. b. discard items that may have been in contact with the area below waist level. c. place the povidone-iodine bottle well within the sterile field. d. place sterile items on the very edge of the sterile drape.

ANS: B A sterile object held below a person's waist is considered contaminated. To maintain sterile asepsis, discard items that may have been in contact with the area below waist level. Sterile gloves are not put on before opening sterile packages, because the outside of the package is not sterile. The nurse uses hand hygiene and opens sterile packages while being careful to keep the inner contents sterile. Povidone-iodine and chlorhexidine are not considered sterile solutions and require separate work surfaces for prepping. The edges of a sterile field are considered to be contaminated. Sterile items should be placed in the middle of the sterile field to maintain sterile asepsis. DIF: Cognitive Level: Application REF: Text reference: p. 262 OBJ: Perform the following skills: applying sterile gloves using open glove method, preparing a sterile field, applying a sterile drape correctly. TOP: Sterile Field KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

7. Which of the following is an appropriate technique for the nurse to use when performing sterile gloving? a. Put the glove on the nondominant hand first. b. Interlock the hands after both gloves are applied. c. Pull the cuffs down on both gloves after gloving. d. Grasp the outside cuff of the other glove with the gloved hand.

ANS: B After the second glove is on, interlock the hands above waist level. Be sure to touch only sterile sides. Gloving of the dominant hand first improves dexterity. The cuffs usually fall down after application. With a gloved dominant hand, slip fingers underneath the second glove's cuff. The cuff protects gloved fingers. Sterile touching sterile prevents glove contamination. DIF: Cognitive Level: Application REF: Text reference: p. 269 OBJ: Perform the following skills: applying sterile gloves using open glove method, preparing a sterile field, applying a sterile drape correctly. TOP: Applying Sterile Gloves KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

2. The nurse is applying for a job at a local hospital. She wants to look her best for the interview and decides to wear artificial nails. She does this knowing that artificial nails: a. are appropriate in the ICU setting as long as the nurse washes her hands frequently. b. can lead to fungal growth under the nail. c. can actually lower the bacterial count on the hands because they cover the natural nail. d. are banned only in areas where patients are critically ill.

ANS: B Numerous reports identify that fungal growth frequently occurs under artificial nails as a result of moisture becoming trapped between the natural nail and the artificial nail. Because of the risks for infection posed by artificial nail use, health care workers who have direct contact with patients at high risk (e.g., those in intensive care units or operating rooms) should not wear artificial nails. Health care workers who wear artificial nails or nail extenders are more likely to harbor gram-negative pathogens on their fingertips, both before and after handwashing. Many health care institutions have chosen to ban artificial nails and extenders in all clinical areas, with the rationale that all patients are at risk for infection. DIF: Cognitive Level: Application REF: Text reference: p. 257 OBJ: Identify principles of surgical asepsis. TOP: Artificial Nails KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

1. When the following concepts are compared, which is most important in maintaining a safe environment by following aseptic principles? a. Performing a surgical hand scrub b. Applying a sterile gown c. Recognizing the importance of following aseptic principles d. Applying a mask and protective eyewear

ANS: C A nurse in an operating room follows a series of steps toward sterile technique, such as applying a mask, protective eyewear, and a cap; performing a surgical hand scrub; and applying a sterile gown and sterile gloves. In contrast, a nurse who is performing a sterile dressing change at a patient's bedside or in the home setting may only wash the hands and apply sterile gloves. Regardless of the procedures followed or the setting, the nurse needs to recognize the importance of following strict aseptic principles. DIF: Cognitive Level: Application REF: Text reference: p. 257 OBJ: Identify principles of surgical asepsis. TOP: Aseptic Principles KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

8. The nurse is preparing to insert a urinary catheter. The package is dry but shows signs of yellowing inside the plastic wrapper, as if the package was wet at one time. What should the nurse do? a. Use the package because it is dry at present. b. Consider the outer package contaminated, but the inner package sterile. c. Discard the entire package as contaminated. d. Open the package and consider the 1-inch border as contaminated.

ANS: C A sterile barrier that has been permeated by punctures, tears, or moisture must be considered contaminated. If there is any question or doubt of an item's sterility, the item is considered to be unsterile. Once a sterile package has been opened, a 2.5-cm (1-inch) border around the edges is considered unsterile. DIF: Cognitive Level: Application REF: Text reference: p. 257 OBJ: Explain the importance of organization and caution when using surgical aseptic techniques. TOP: Principles of Surgical Asepsis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

4. An appropriate principle of surgical asepsis is that: a. the entirety of a sterile package is sterile once it is opened. b. all of the draped table, top to bottom, is considered sterile. c. an object held below the waist is considered contaminated. d. if the sterile barrier field becomes wet, the dry areas are still sterile.

ANS: C A sterile object or field out of the range of vision or an object held below a person's waist is contaminated. Once a sterile package is opened, a 2.5-cm (1-inch) border around the edges is considered unsterile. Tables draped as part of a sterile field are considered sterile only at table level. A sterile barrier that has been permeated by punctures, tears, or moisture must be considered contaminated. DIF: Cognitive Level: Application REF: Text reference: p. 262 OBJ: Perform the following skills: applying sterile gloves using open glove method, preparing a sterile field, applying a sterile drape correctly. TOP: Sterile Field KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

10. A nurse is preparing a sterile field for a dressing change using surgical aseptic technique. The nurse gathers supplies to prepare the sterile field using a packaged drape. Which option correctly describes how the nurse should set up the field? a. Don sterile gloves before opening the packaged drape. b. Clean the bottle of irrigation solution with alcohol before placing the bottle on the field. c. Avoid dropping sterile supplies close to the 1-inch border around the drape. d. Leave the sterile field unattended to obtain needed supplies.

ANS: C The exterior border of the sterile drape is presumed contaminated, so all supplies must be kept within the sterile portion. Dropping supplies too close to the 1-inch border risks having them bounce off the sterile area. Nonsterile supplies are never to be placed on the sterile field. The sterile field is never to be out of the nurse's line of sight. Sterile gloves will not be applied until the sterile field is set up, and items needed to deliver care are ready for use. Applying them earlier in the process risks having them become contaminated. DIF: Cognitive Level: Application REF: Text reference: p. 264 OBJ: Prepare a sterile field and use a sterile drape correctly. TOP: Using Surgical Asepsis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

9. A type I hypersensitivity to latex is evident if the nurse assesses: a. localized swelling. b. skin redness and itching. c. runny eyes and nose and cough. d. tachycardia, hypotension, and wheezing.

ANS: D Type I allergic reaction is a true latex allergy that can be life threatening. Reactions vary on the basis of the type of latex protein and the degree of individual sensitivity, including local and systemic. Symptoms include hives, generalized edema, itching, rash, wheezing, bronchospasm, difficulty breathing, laryngeal edema, diarrhea, nausea, hypotension, tachycardia, and respiratory or cardiac arrest. Type IV hypersensitivity is a cell-mediated allergic reaction to chemicals used in latex processing. Reaction, including redness, itching, and hives, can be delayed up to 48 hours. Localized swelling, red and itchy or runny eyes and nose, and coughing may develop. Irritant dermatitis is a nonallergic response characterized by skin redness and itching. DIF: Cognitive Level: Comprehension REF: Text reference: p. 266 OBJ: Identify individuals at risk for latex allergy. TOP: Levels of Latex Reactions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

When sterile procedures are carried out in the OR or procedure area, health care providers must follow a series of steps to maintain sterile asepsis:*

applying a mask, protective eye wear, and cap; performing a surgical hand scrub; and applying sterile gown and gloves.+

When completing a sterile procedure at the bedside, communicate with the patient about which steps are begin taken to percent infection, including which actions the patient should avoid to keep the field sterile. These actions include*

avoiding sudden body movements, refraining from touching sterile supplies, and avoiding coughing or talking over sterile area.+

Surgical aseptic technique is also used at the bedside in the following situations: during procedures that require*

intentional puncture of the skin or insertion of devices into an area of the body that is normally sterile or in a situation in which skin integrity is compromised because of incision or burn.+

Unexpected Outcome: Redness, heat, edema, pain, or purulent drainage develops at wound or treatment site, indication possible infection*

notify hcp of change in condition of affected area and initiate appropriate treatments as ordered.+

Take into consideration the patient;s cultural background or beliefs when sterile asepsis is required. Individualized patient-centered education for patients and families before an aseptic procedure .*

reduces fears and misconceptions about sterile asepsis attire. This also providers and opportunity for patients and families to ask question and express their concerns regarding surgical attire+

Whether performed in a hospital , ambulatory care setting, the patient's home, or health care provider's office, invasive procedures such as starting an intravenous line or inserting a urinary catheter pose a risk for infection. It is your responsibility to protect patients from infection by adhering*

strictly to the principles of surgical asepsis when performing invasive procedures or when helping with such a procedure and to intervene to stop it when a break in sterile technique occurs. The joint Commission encourages nurses to speak up in these instances.+