AEI On-Campus Simulation

3A group of nurses are reviewing information about asepsis. Which statement by the group demonstrates the need for additional review?

: A sterile field becomes contaminated if the nurse turns his or her back to it. Any item that comes into contact with a sterile field must be sterile. Reaching over a sterile field contaminates the sterile field. Any items below waist level are considered contaminated.

A nurse is preparing to use an alcohol-based handrub for hand hygiene. After applying the appropriate amount of product, the nurse would rub the hands together for at least how long?

15 sec

4Which client would be at greatest risk for developing a pressure injury?

A client who is comatose is at greatest risk for developing a pressure injury due to the inability to turn or move in bed. This client needs to be turned regularly to prevent development of a pressure injury. The other clients have no restrictions for movement and would not be at great risk for developing a pressure injury. An older client who is bedridden (not a factor with COPD) would also be at high risk for developing a pressure injury due to age-related skin alterations.

The charge nurse notices that when caring for a client, some nurses are wearing personal protective equipment and other nurses are not. Which action would be most appropriate for the nurse to take

Consult the agency's infection control manual. If there is a question about transmission-based precautions when caring for a client, the nurse should check the agency's infection control manual and the institution's policies about specific illnesses. Then the nurse should review the mode of transmission associated with the specific microorganism causing the illness. Although asking the health care provider about the client's condition and reviewing the medication record can provide additional information, the infection control manual and policies would be most appropriate to use. Checking with other staff nurses on the unit would be inappropriate because their actions could be inconsistent.

A nurse is preparing to perform hand hygiene using an alcohol-based handrub. When applying the product, the nurse would place the product at which location?

In the palm of one hand: The proper procedure for using an alcohol-based handrub is to apply the appropriate amount of product to the palm of one hand. This helps to ensure that the product will cover all the surfaces when the product is rubbed in. The nurse would rub the hands together, covering all surfaces of hands and fingers, between fingers as well as the fingertips and the area beneath the fingernails. It would be inappropriate to apply the product to each fingertip, on the back of the hand, or between each finger.

The nurse observes a reddened area with intact skin over the client's coccyx. When gentle pressure is applied, the area does not blanch. How will the nurse document this finding?

This finding should be documented as a stage 1 pressure injury. The description of stage 1 pressure injury includes intact skin with nonblanchable redness. In a stage 2 pressure injury, the skin would not be intact, and there is partial-thickness skin loss involving epidermis, dermis, or both. Deep tissue injuries are characterized by a purple or maroon localized area of discolored intact skin or blood-filled blister caused by damage to underlying soft tissue from pressure and/or shear. An unstageable pressure injury has slough, which is a yellowish stringy substance attached to the wound bed, or eschar, which is black or brown necrotic tissue covering the wound, which prevents knowledge of the depth of the wound.

An older adult woman has been in the hospital for more than 1 week. While assessing her intravenous catheter port, the nurse finds a staph infection, which has developed in the past day or so. This infection is an example of which type of infection?

This infection is best described as a health care-associated infection. A health care-associated infection is an infection not present on admission to health care agency and that has been acquired during the course of treatment for other conditions. The other terms listed do not apply to this infection.

The nurse prepares to enter a client's room where goggles are required but are not available. Which action by the nurse is best?

Wear a face shield as part of the protective equipment. The nurse would not delay care due to a lack of goggles. The acceptable alternate is a face shield, which is a mask with a clear plastic covering for the eyes. If goggles are needed, the nurse would not enter the room without eye covering unless there was an emergent reason to do so. However, it is not correct to delay care until goggles can be obtained. This can take quite a long time. Even if the goggles can be supplied soon, the nurse can easily locate and use a face shield.

The nurse is changing the dressing of a client whose skin has been irritated by the frequent removal of adhesive tape that holds the dressing in place. Which would be a recommended nursing intervention?

When a client's skin around a wound has been irritated by frequent removal of tape, the nurse would consider using Montgomery straps, non-allergenic tape, or dressing ties, instead of adhesive tape, to hold the dressing in place. A skin barrier could also be used on the skin around the wound (not on the wound itself). Alcohol wipes or antimicrobial wipes would not be used, as they would further irritate the skin.

The nurse is removing the dressing from an abdominal surgical wound during wound care and notices that the wound edges are not intact, there are multiple staples on the dressing, and the surrounding tissue is red with purulent drainage. The chart reports that the incision was clean and dry with the approximated edges and staples intact upon the last assessment. What would be the first recommended nursing intervention in this situation?

When excessive drainage appears on the dressing, the nurse would first assess the client for pain, shortness of breath, and abdominal pressure, and then place the client in the supine position to reduce pressure on the abdomen. The nurse would then place a dry, sterile dressing on the wound site and assess vital signs, while reassuring the client that while the wound condition has changed, he/she is all right and the health care provider will be notified immediately.

The nurse is wearing a gown and gloves as part of using personal protective equipment. The gown is tied in the front at the waist and at the neck. Which action would the nurse take first?

When removing personal protective equipment, a gown that is tied in the front at the waist is unfastened first because the front of the gown, including the waist ties, are considered contaminated. The nurse would then remove the gloves, one at a time, so that one glove is contained within the other. After discarding the gloves, the nurse would then untie the gown at the neck and back

The nurse is changing the dressing on a client's surgical wound. After the old dressing is removed, the nurse notices that the client's skin is red and blistered where the dressing had been secured with tape. Which would be an appropriate action by the nurse?

When replacing a dressing that has caused blisters on the underlying skin, the nurse would cleanse the area thoroughly, being careful not to aggravate the reddened and blistered areas, and could place a new, larger dressing over the wound so that the blistered area is not further aggravated by tape.

The nurse uses soap and water for hand hygiene. Which action demonstrates proper handwashing?

When washing the hands with soap and water, the nurse would use a rubbing circular motion to wash the palms and back of the hands, each finger, the areas between the fingers and knuckles, and the wrists and forearms. Throughout the process, the nurse would keep the hands lower than the elbows to allow water to flow toward the fingertips. The nurse would wash to at least 1 in (2.5 cm) above the level of contamination or to 1 in (2.5 cm) above the wrists. When drying the hands, the fingers are dried first and the nurse then moves upward toward the forearms.

What is the best source for the nurse to determine the type of transmission precautions a client needs?

Client's medical record: The client's medical record includes the type of precautions to observe and the laboratory reports to verify the organism. The sign on the client's room may be incorrect. Nurses typically ensure the client is on the correct precautions. The assigned nurse updates the charge nurse's report regarding transmission precautions.

18The charge nurse confronts a new nurse about not wearing gloves into a client's room. The client is not on transmission-based precautions. How does the new nurse best respond?

"Can you show me the hospital policy for when to wear gloves?" When there is any doubt, the facility resources should be consulted for verification of existing policies regarding transmission-based and standard precautions. This question prevents the nurse from arguing with the charge nurse, too. Gloves are not required for every client interaction.

The client asks the nurse why the nurse wears a disposable gown every time she enters the client's room. What is the nurse's best response?

"I am required to wear a gown for certain infections that are easily passed to others." The client needs a matter-of-fact response that does not make him or her feel dirty, guilty, or confused. The nurse teaches the client in a direct way that some infections are easier to spread, making additional precautions necessary for everyone's protection. It is dismissive to say it is policy or just that there i

The new nurse notes a health care provider enter a client's room without the correct personal protective equipment (PPE). What does the nurse say to the health care provider?

"I notice you did not wear the required PPE." It is incorrect to confront the provider in a confrontational or accusatory manner. Once the nurse states that this behavior has been observed, the nurse and provider can have a discussion

The nurse assesses the surgical dressing of a client who has just arrived from the post-anesthesia care unit (PACU) and observes the dressing has a moderate area of serous drainage on it. What is the best action by the nurse?

Because bleeding is expected during the first 12 to 24 hours after surgery, the best action by the nurse is to reinforce the dressing and assess the site frequently. Because this is the first surgical dressing that was applied by the surgeon, only the surgeon should change the dressing. Bleeding is expected and, therefore, the health care provider does not need to the notified. Calling a rapid response is not needed in this situation.

The nurse is caring for a Jackson-Pratt drain. Place in order, from first to last, the actions the nurse will perform. Use all options.

1)Place the graduated collection container under the drain outlet. 2)Remove the cap from the bulb. 3)Empty the bulb's contents into the collection chamber. 4)Wipe the outlet of the bulb with a sterile gauze pad. 5)Fully compress the bulb. 6)Replace the cap on the bulb

A nurse is preparing to perform hand hygiene using an alcohol-based handrub. Place the following steps in the correct order. Use all options.

1)Remove jewelry 2)Check the product label for the correct amount to use 3)Apply the product 4)Rub the hands together, covering all surfaces of the hands and fingers 5)Ensure that the hands are dry

The nurse is preparing to perform handwashing. Place the following steps in the correct order. Use all options.

1)Turn on the faucet and adjust the force and temperature of the water. 2)Wet the hands and wrists. 3)Apply soap. 4)Wash the palms and backs of the hands for at least 20 seconds. 5)Pat the hands dry with a paper towel. 6)Turn the faucet off with a paper towel.

Place in correct order the steps for removing a gown. Use all options.

1)Unfasten the ties. 2)Touching only the inside of the gown, pull away from the torso. 3)Keeping hands on the inner surface of the gown, pull gown from arms. 4)Turn gown inside out. 5)Fold or roll the gown into a bundle. 6)Discard the gown.

The nurse is performing hand washing using soap and water after providing client care. The nurse has performed hand hygiene using soap and water. What action would the nurse take next?

: After rinsing the hands, the nurse would dry the hands using paper towels, wiping from the fingertips toward the forearms. Once dry, the nurse would then use another clean paper towel to turn off the water at the faucet to prevent clean hands from coming in contact with the soiled surface. The fingernails are cleaned before the hands are rinsed. The hands are dried using clean paper towel. An alcohol-based sanitizer or hospital-provided lotion can be used after handwashing and drying, if desired.

vThe nurse determines that the sterile field has been contaminated when which action occurs?

A sterile field becomes compromised if the nurse turns away from it, if it drops below waist level, if an object falls onto or outside of the 1-in (2.5-cm) border of the field, or if the nurse reaches over the sterile field.

How would the nurse secure a Jackson-Pratt drain after emptying it?

After performing drain care, the nurse would secure the Jackson-Pratt drain to the client's gown below the wound with a safety pin, making sure there is no tension on the tubing.

A nurse demonstrates the correct use of hand hygiene using an alcohol-based handrub for which situation? Select all that apply.

After removing gloves, Before entering a client's room, After applying a clean, dry dressing: An alcohol-based handrub can be used if hands are not visibly soiled or have not come in contact with blood or body fluids. Appropriate situations would include before entering a client's room, after removing gloves, and after applying a clean, dry dressing. Soap and water should be used before eating and after using the restroom.

The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and adheres to the wound bed. Which modification is most appropriate?

Allowing the dressing material to dry will disrupt healing tissue. Therefore, the time interval between dressing changes should be reduced to prevent the dressing from drying out. Too much moisture in the dressing may cause maceration. Shortening the time interval between dressing changes is more appropriate than increasing dressing moisture. There is no indication that too much packing material was used. A hydrocolloid dressing in not indicated.

The nurse is caring for a client with a Jackson-Pratt drain. Which intervention by the nurse is priority before beginning the dressing change?

Although all noted interventions may be indicated, assessing the need for analgesia is priority. The nurse should administer appropriate prescribed analgesic and then allow enough time for the analgesic to achieve its effectiveness before beginning the procedure.

Which are basic principles of surgical asepsis? Select all that apply

Avoid talking, coughing, sneezing, or reaching over a sterile field., Only a sterile object can touch another sterile object., Consider the outer 1-inch (2.5 centimeters) edge of a sterile field to be contaminated., Never turn the back on a sterile field.

When removing a client's surgical wound dressing, the nurse notes that there is wound separation and rupture. What is the term for this wound complication?

Dehiscence is the term for the accidental separation of wound edges, especially a surgical wound. Ecchymosis is discoloration of an area resulting from the infiltration of blood into the subcutaneous tissue. A sinus tract is a cavity or tunnel underneath a wound that has the potential for infection, and undermining occurs when there are areas of tissue destruction underneath intact skin along the margins of a wound.

The nurse is planning to replace a client's wound dressing. The deep wound bed is to remain moist and requires packing. Which action is appropriate?

Gently press to loosely pack the moistened gauze into the wound. Avoid overpacking the gauze; loosely pack to prevent too much pressure in the wound bed, which could impede wound healing. The nurse should not instill normal saline or fill the wound with sterile saline gel, as these will not be effective in keeping the wound moist. Inserting rolled gauze into the wound will likely put too much pressure on the wound bed.

7The nurse is required to wear a gown, gloves, goggles, and mask as personal protective equipment (PPE) when caring for an assigned client. What should the nurse put on first?

Gown: When using personal protective equipment (PPE), the nurse would put on the gown first. Then the nurse would then put on the mask and goggles, and lastly the gloves.

A group of students are demonstrating the skill for hand washing. What would indicate a need for additional teaching?

Hand washing is done for about 20 seconds, followed by a focus on the fingernails prior to rinsing off the soap. When performing hand washing, the water temperature should be warm to the touch. The hands should be kept lower than the elbows at all times to allow water to flow to the fingertips. Firm rubbing and a circular motion promotes friction that helps to loosen dirt and organisms that can lodge between the fingers, in skin crevices of the knuckles, on the palms and backs of the hands, and on the wrists and forearms.

The nurse is changing the dressing on a client's surgical wound and notices that part of the dressing is sticking to the underlying skin. What is the recommended nursing intervention in this situation?

If part of the dressing sticks to the skin, the nurse would use small amounts of sterile saline to loosen and remove the dressing. Sterile saline moistens the dressing for easier removal and minimizes damage and pain.

The nurse prepares to wear personal protective equipment (PPE) when entering a client's room. What action does the nurse take first?

Perform hand hygiene. The nurse must perform hand hygiene before putting on gloves, just like any other time. The nurse does not want to introduce additional infectious organisms to this client. The client's door, for most isolation types, can be opened after PPE is on. Though often done incorrectly, when gowning it is important to ensure the gown covers the back and front of the nurse. As the nurse is dressing in PPE it is wise to double check that the correct transmission precautions are being observed and that each piece of equipment needed is being worn by the nurse. The nurse would not be wrong if wearing more than is required but would not want to wear less than is needed

The nurse is teaching a client's caregiver about ways to help prevent skin breakdown. What would the nurse teach as an important intervention to prevent pressure injury development?

Pressure injuries are a result of unrelieved pressure that damages underlying tissues. Teaching the caregiver to turn and reposition the client every 2 hours is an important intervention to help prevent unrelieved pressure from causing pressure injury to tissues. Keeping the head of the bed elevated will help to prevent aspiration but does not prevent pressure injury. The caregiver should be taught how to use a draw sheet to lift the client and then move the client up in bed. The client should not be pulled, because this causes a shearing force which can easily injure tissue. Reddened areas should not be massage so this should not be taught to the caregiver.

What is the best way for the nurse to ensure there is not any tension on the tubing when caring for a client with a Jackson-Pratt drain?

To ensure there is not any tension on the tubing of a Jackson-Pratt drain, the nurse should secure the drain to the client's gown with a safety pin below the level of the wound. Taping the drain or applying an abdominal binder will keep the bulb compressed and hinder the suction action of the drain. The drain should not be allowed to hang freely because this causes tension on the drain site

The nurse is preparing to clean a client's surgical wound. What would the nurse assess before beginning the procedure?

Prior to cleaning a client's wound, the nurse would assess the client's level of comfort and the need for analgesics before wound care. Wound care may cause pain for some clients. The color of any drainage on wound dressings would be assessed during the wound care procedure. Assessing physical limitations, temperature, and pulses may be appropriate, but these assessments are not directly related to the procedure for cleaning a wound. The procedure for cleaning the wound is the same for a client with or without physical limitations.

The charge nurse observes a new nurse not wearing personal protective equipment (PPE) entering and exiting a client's room. The client is on transmission-based precautions. What is the charge nurse's best response?

Reinforce teaching that transmission-based precautions must be observed. The new nurse may have forgotten, missed the signs, or some other honest error. The charge nurse first offers teaching to the new nurse immediately to prevent further potential harm. An incident report should not be necessary and is not an immediate action. The manager may need to be involved if the issue persists

The nurse notes that a health care provider failed to observe transmission precautions in a client's room and is entering another client's room. What is the nurse's next action?

Remind the health care provider about the transmission precautions. It is best to directly and immediately address the issue with the health care provider. The nurse may suggest that additional precautions are taken prior to entering the client's room, but really can't insist, and hand hygiene is expected for every client. The charge nurse or supervisor can intervene, following the chain of command, if the health care provider does not take corrective action.

9The nurse is caring for a client with a pressure injury and is applying a saline-moistened dressing to the wound. What does the nurse understand to be the primary rationale for using a saline-moistened dressing?

Saline-moistened dressings are used to maintain a moist wound environment to promote moist wound healing and protect the wound from contamination and trauma. A moist wound surface enhances the cellular migration necessary for tissue repair and healing. It is important that the dressing material be moist, not wet, when placed in open wounds. Although a moist dressing may also prevent sticking to the wound, this is not its primary purpose.

Personal protective equipment (PPE) is used in health care facilities for primarily which reason?

To protect both the staff and clients from becoming infected by one another To protect both the staff and clients from becoming infected by one another

Which client is a greatest risk of developing a pressure injury?

The 47-year-old client with severe alcoholism (poor nutritional status) and a traumatic brain injury (immobile) is at greatest risk for developing a pressure injury. The 17-year-old does not have any noted risk factors, the 25-year-old is young and only on bedrest for 24 hours so is very unlikely to develop a pressure injury, and the 84-year-old is ambulatory, making them a low risk for a pressure injury. For the 84-year-old client, the greatest risk is for falls.

The nurse performs hand hygiene using an alcohol-based handrub after exiting a client's room. The nurse does not touch another surface or client until what has occurred?

The antiseptic has evaporated from the skin. Although products may vary, typically the nurse would apply the antiseptic to the palm of the hand, covering all surfaces of the hands and fingers. The nurse would continue to rub until the antiseptic until it evaporates from the hand. Hand hygiene is not documented. Thirty seconds may not be enough time for the solution to dry. Hands are not dried with a paper towel after using the alcohol-based handrub.

Which assessment findings will the nurse use to determine the stage of a client's pressure injury? Select all that apply.

The assessment findings which will help the nurse determine the stage of a client's pressure injury are: subcutaneous fat is visible; there is full-thickness tissue loss; and no bone, tendon, or muscle is visible in the wound bed. This information should lead the nurse to document this as a stage 3 pressure injury. The skin being red and warm to the touch and the green foul drainage are indications of wound infection, but do not influence the staging of the client's pressure injury.

The nurse is caring for a client with a pressure injury on the heel of the foot. The injury is covered with stable black eschar. What is the best nursing intervention at this time?

The best nursing intervention at this time is to teach the client ways to relieve the pressure on the heel to prevent further damage. Stable eschar serves as "the body's natural (biological) cover" and is only removed by health care provider order. Teaching the client to reposition is a good intervention, but the client should be taught to reposition at least every 2 hours. The client would need adequate protein to promote healing, not carbohydrate.

The nurse prepares the sterile tray for indwelling catheter insertion while wearing sterile gloves. The nurse then pulls the client's blankets away from the pelvis to begin catheter insertion. What action should the nurse take next?

The client must be prepared prior to preparing the catheter kit. The nurse must wear sterile gloves while preparing the sterile tray, because it involves opening sterile supplies. If the nurse then touches a non-sterile surface, like the client's blankets, the sterile gloves must be changed prior to continuing the procedure. The nurse does not need to reposition the kit at this time. The nurse is no longer sterile and cannot proceed with cleaning the client with sterile solution. Only the nurse's gloves are contaminated; the nurse does not need to dispose of the kit.

The nurse is wearing a gown as part of using personal protective equipment and is preparing to put on clean disposable gloves. Which placement indicates that the nurse has put on the gloves properly?

The glove ends extend to cover the gown's cuffs

The nurse has finished cleaning a client's surgical wound. What would be the nurse's next action in this procedure?

The next step after cleaning a client's wound is to dry the wound with a sterile gauze sponge in the same manner in which it was cleaned, moving from top to bottom and from the inside to the outside of the wound. Moisture provides a medium for the growth of microorganisms. The nurse should not air dry the wound but pat it dry with a sterile gauze. Measuring the wound should happen after removing the old dressing. At that time the nurse should assess the wound, wound bed, drainage, and measure the wound. Positioning of the client should happen before beginning the procedure.

The nurse prepares for a sterile dressing change on one end of the table by opening a sterile field and dropping the supplies onto it. The nurse needs to gather additional supplies remaining on the other side of the table. What action does the nurse take?

The nurse can step around the edge of the table, without turning his or her back on the sterile field, to gather the remaining supplies. Reaching across the current sterile field would be a reason to discard all the supplies and the field due to contamination. The table does not need to be completely covered with sterile drapes.

When washing the hands with soap and water what is an appropriate action for the nurse to perform

The nurse keeps the hands lower than the elbows to allow water to flow toward fingertips. When hand washing, the nurse washes jewelry, usually restricted to only a wedding band, before starting; jewelry can harbor microorganisms and contaminants. Next, the nurse would turn on the water, apply soap to the hands, and rub it in using a circular motion. After thoroughly cleaning the hands, the nurse would then clean under the nails. The nurse does not lean on the sink as this can lead to contamination.

When assessing a client's skin, the nurse observes an area of deep purple discoloration on the client's heel. The skin in that area is intact. How will the nurse document this finding?

The nurse should document this finding as a deep tissue injury. Deep tissue injuries are characterized by a purple or maroon localized area of discolored intact skin or blood-filled blister caused by damage to underlying soft tissue from pressure and/or shear. The description of stage 1 pressure injury includes intact skin with non-blanchable redness. In a stage 2 pressure injury, the skin would not be intact, and there is partial-thickness skin loss involving epidermis, dermis, or both. An unstageable pressure injury has slough, which is a yellowish stringy substance attached to the wound bed, or eschar, which is black or brown necrotic tissue covering the wound, which prevents knowledge of the depth of the wound

How often will the nurse empty a Jackson-Pratt drain? Select all that apply.

The nurse should empty the Jackson-Pratt drain when the drain is one-half to two-thirds full and at least every 4 hours. The nurse should not wait until the drain is full, because this could interfere with the proper functioning of the drain. Once per shift or once per day is not often enough to catch any early indications of a complication.

Place in order, from first to last, these actions the nurse will perform when providing wound care to a client with a pressure injury. Use all options.

The nurse should first put on clean gloves, then remove the old dressing, assess the wound bed and surrounding skin, change gloves, open dressing materials, provide the wound care including irrigating the wound bed, then time and date the dressing once completed.

The nurse is preparing to perform wound care. Which intervention should be implemented to protect the nurse from injury?

The nurse would adjust the bed to a comfortable working position, usually elbow height. Having the bed at the proper height prevents back and muscle strain for the nurse. Maintaining a sterile field prevents risk of infection for the client. Positioning the client is to make the wound accessible for care. Gathering equipment helps the nurse be organized, not prevent injury.

After setting up a sterile field and putting on sterile gloves, the nurse prepares to clean a client's surgical wound. Which cleaning technique would the nurse use to prevent contamination of the wound? The nurse cleans the wound from the:

The nurse would clean the wound from the top to the bottom and from the center to the outside using a new gauze for each wipe. This method ensures that the cleaning is from the least to the most contaminated area and a previously cleaned area is not contaminated again. Cleaning from outside to center, from side to side, or from distal to proximal increases the risk of contaminating the wound as the nurse is starting in the most contaminated area and cleaning into the wound.

The nurse wears personal protective equipment (PPE) when entering the client's room. What is the nurse's goal in wearing PPE?

The nurse's goal is to prevent infection transmission, including from other clients to this client and from this client to other clients. The nurse does not necessarily have an infection. The nurse is adhering to policy, but that is not the goal of using PPE during client care. The gown protects the nurse's other clients from an infectious organism, but the goal is not prevention of infection in the nurse, though that is a desirable outcome

The nurse is caring for a client's wound that has a Jackson-Pratt drain in place. What would be the nurse's next step after emptying the chamber's contents into the graduated collection container?

The order in which the nurse would perform the steps to care for a Jackson-Pratt drain is (1) empty the chamber's contents completely into the container, (2) use the gauze pad to clean the outlet, (3) fully compress the chamber, and (4) replace the cap. Clean gloves would be put on prior to emptying the chamber.

Which includes practices used to render and keep objects and areas free from microorganisms?

This statement describes surgical asepsis, or sterile technique. Medical asepsis, or clean technique, involves procedures and practices that reduce the number and transfer of pathogens. Hand hygiene is a type of medical asepsis specific to the hands and includes hand washing and use of alcohol-based handrubs.

After emptying the drainage from a Jackson-Pratt drain, how will the nurse re-establish suction to the drain?

To re-establish suction after emptying a Jackson-Pratt drain, the nurse should fully compress the bulb and then reapply the cap. Applying the cap before compressing the bulb will not allow the air to escape and, therefore, no suction can be applied. Wall suction is not used with the Jackson-Pratt drain.

The nurse removes personal protective equipment after caring for a client on transmission-based precautions. Which action by the nurse is correct?

Touch the inside of the gown and pull it away from the torso. The outside of the equipment is considered contaminated. Removal follows a prescriptive sequence. Most personal equipment is removed at the door of the client's room. The contaminated glove grasps the other contaminated glove for removal. The nurse's clean hand reaches under the other glove for removal. Goggles are removed by holding the earpieces. Clean hands touch the inside of the gown for removal, pulling away from the torso. Roll these items up, inside out, for disposal. Grasp ties on mask on respirator for removal after leaving the room.

The nurse is removing a gown after providing care to a client. Which action would the nurse take first?

When removing a gown, the nurse first unfastens the ties at the neck and back, and then allows the gown to fall away from the shoulders. Touching only the inside of the gown, the nurse pulls the gown away from the torso. Keeping the hands on the inner surface of the gown, the nurse pulls the gown from the arms, turns it inside out, and folds or rolls it into a bundle to be discarded.

13Which item would the nurse remove first when removing personal protective equipment?

When removing personal protective equipment (PPE), the first item to be removed is the gloves. If the gown is tied in the front, the nurse unties the gown first and then removes the gloves. The face shield is removed next, followed by the gown, and lastly the mask.

The nurse has documented that a client has an unstageable pressure injury. Which statement best describes this type of wound? The wound:

Wounds that have slough (yellow, tan, gray, green, or brown stringy tissue) or eschar covering them are considered unstageable as it is not possible to determine their depth until the slough or eschar is removed. A wound that has exposed bone, tendon, or muscle visible would be considered stage 4. A wound that has redness with partial thickness loss of dermis would be considered stage 2, and a wound with bright red granulation tissue in the wound bed would be considered healing, although there is not enough information to stage this wound.