Exam #1 Module 2&3

One evaluation measure of creating and maintaining a sterile field involves monitoring the patient for developing signs and symptoms of localized or systemic infection. Which of the following is cause for concern? A- Temperature of 102.5° F (39.2° C). B-Incision area light pink in color. C-White blood cell count at 6500 per mm3 D-Absence of purulent drainage.

A

The nurse is caring for four individuals. Which patient would be most at risk for infection? A-The patient who is receiving immunosuppressive medication. B-The patient who is unable to shower without assistance. C-The patient with a history of a latex allergy. D-The patient who exercises daily in a swimming pool.

A

The nurse is preparing to insert a urinary catheter. To perform this procedure, the nurse will use: A-Surgical asepsis (sterile technique). B-Medical asepsis (clean technique). C-Droplet precautions. D-Standard precautions.

A

The nurse is working in a busy emergency room. On entering station 1, the nurse dons a pair of clean disposable gloves. The nurse sees that the patient has a gunshot wound to the chest and is concerned there may be splattering of infectious materials. The nurse applies goggles, a mask, and a gown. What is this called? A-Following standard precautions. B-Using medical asepsis. C-Using surgical asepsis. D-Infection control to prevent a health care-acquired infection.

A

Why are the hands rinsed with the fingertips held lower than the wrist? A-Water flows from the least to the most contaminated area, rinsing microorganisms into the sink. B-To keep the sleeves from getting wet. C-It is necessary to ensure that all surfaces of the hands, including under the nails, are cleansed. D-To loosen and remove dirt and bacteria.

A

A small group of nursing students is giving a teaching presentation on the principles of surgical asepsis. Which of the following standards are appropriate to include in the presentation? (Select all that apply.) A-A sterile barrier that has been permeated by moisture must be considered contaminated. B-A sterile object or field out of the range of vision or an object held below a person's waist is considered contaminated. C-A sterile field or object cannot become contaminated by air. D-If there is any doubt about an item's sterility, the item is considered to be unsterile. E-All items used within a sterile field must be sterile.

A sterile barrier that has been permeated by moisture must be considered contaminated. A sterile object or field out of the range of vision or an object held below a person's waist is considered contaminated. If there is any doubt about an item's sterility, the item is considered to be unsterile. All items used within a sterile field must be sterile.

When is it acceptable to use antiseptic hand rub rather than soap and water? (Select all that apply.) A-After adjusting a nasal cannula on a patient. B-After removing gloves after changing a wound dressing. C-When the nurse's hands are cracked from frequent hand hygiene. D-After moving patient's belongings on the bedside table. E-After the patient develops a skin tear and blood is on the nurse's hand.

After adjusting a nasal cannula on a patient. After removing gloves after changing a wound dressing. After moving patient's belongings on the bedside table.

A nurse assists a patient with a Foley catheter to ambulate down the hall. The nurse holds the catheter bag below the level of the patient s bladder. What link in the chain of infection is the nurse breaking by doing so? A-Portal of exit. B-Portal of entry. C-Reservoir. D-Host susceptibility.

B

A nurse is preparing a medication for subcutaneous administration. As the nurse recaps the needle using the scoop method, the nurse accidentally touches the table with the uncovered needle. What is the nurse's best action? A-Discard the needle, syringe, and medication and start over. B-Discard the needle and replace with a new one before administration. C-Wipe the needle with an alcohol swab and recap for use. D- Transfer the medication to a new syringe.

B

A nurse is teaching infection control to a group of daycare workers. Which of the following should the nurse include in the instruction? A-Washing hands with soap and water is the only effective means for stopping the spread of germs. B-Immunizations help protect children from being susceptible hosts. C-Large containers of hand sanitizer should be made available for use when there is visible soiling. D-Toys are typically the reservoir of pathogen growth.

B

A patient was diagnosed with a urinary tract infection. The patient has been drinking fruit juice and has increased his intake of fluids but has failed to take his antibiotic as prescribed because it caused gastric upset. Three days later, the patient presents to the clinic with fever, malaise, nausea, and vomiting. What might you suspect? A-The patient probably has the flu. B-The patient may now have a systemic infection. C-The patient is displaying signs of a localized infection. D-The patient is experiencing an allergic response to his medication.

B

The nurse is adding a dry sterile gauze dressing to the sterile field. The dressing bounces on the surface and lands on the outer 1-inch border of the sterile field. What action is appropriate at this time? A-The nurse discards the entire sterile field, all items on it, and starts over. B-The nurse opens another sterile gauze dressing and adds it to the sterile field, but does not use the first one. C-Once sterile gloves are applied, the nurse moves the sterile gauze dressing to the center of the sterile field. D-The nurse continues with the procedure adding supplies to the sterile field and using each of them as needed.

B

The nurse is reviewing with the surgical technician how to prepare a sterile field. Which of the following is incorrect and should not be included in the review? A-Keep your intended work surface above waist level. B-Place the drape so the top half of the drape is over the top half of the work surface. C-You may grasp the outer 1-inch border of the drape without wearing sterile gloves. D-Place sterile items onto the sterile field at an angle.

B

The nursing instructor is asking the nursing students to share their knowledge regarding sterile gloving. Which statement, if made by a student, would require correction? A-Be sure to select appropriate size gloves. Gloves that are too small can tear more easily. B-Once sterile gloves are applied, the inside of the glove is still considered sterile. C-Be sure to select appropriate size gloves. Gloves that are too large can impede your ability to pick up items and perform your task. D-If you touch a nonsterile item with your sterile gloved hands, you should remove the gloves and obtain a new pair.

B

What is the best nursing practice to reduce the potential transmission of microorganisms within the health care setting? A-Bagging all linen. B-Performing hand hygiene. C-Keeping catheter bags empty. D-Wearing gloves.

B

When should you perform hand hygiene? (Select all that apply.) A-Before applying gloves to insert an IV. B-After documenting in the patient's electronic medical record. C-After moving a patient up in bed. D-Before assessing a patient's vital signs. E-Before touching clean linens.

Before applying gloves to insert an IV. After moving a patient up in bed. Before assessing a patient's vital signs.

Which of the following is a correct description of glove removal? A-You pull the gloves off by the fingertips and discard them in a proper receptacle. B-You grasp the inside of one glove with the other gloved hand, pull the glove off, and discard it in a proper receptacle. The remaining glove is removed by placing the fingers of the bare hand outside the cuff, pulling the glove off, and discarding it in a proper receptacle. C-You grasp the outside of one cuff with the other gloved hand and pull the glove off, turning it inside out, and place it in gloved hand. Take fingers of bare hand and tuck inside remaining glove cuff against the skin. Peel glove off inside out and over the previously removed glove. Discard both gloves in receptacle. D-You slide the gloved fingers of the dominant hand under the inside cuff of the nondominant hand and pull the glove off and discard. Then you slide the fingers of the nondominant hand under the cuff of the dominant hand and pull the glove off and discard.

C

The nurse is applying sterile gloves. Which series of steps would require correction? A-Perform hand hygiene. Examine glove package to determine if it is dry and intact. Open sterile gloves by carefully separating and peeling open the adhered package edges. Identify right and left glove. B-With thumb and first two fingers of nondominant hand, grasp edge of the cuff of the glove for the dominant hand. Touch only inside surface of the glove and pull the glove over the dominant hand, carefully working the thumb and fingers into the correct spaces. Gently let go of the cuff while preventing it from rolling up the wrist. C-Slide the fingers of the gloved hand underneath the second glove's cuff. Pull the glove over the fingers of the nondominant hand. Avoid touching exposed areas with the gloved hands. D-Hold gloved hands at sides of body, below waist level, until beginning the sterile procedure.

D

The nurse is preparing to set up a sterile field for a patient who is going to have a sterile dressing change. Which of the following assessment measures would be unnecessary at this time? A-The nurse reviews documentation to see what supplies will be needed. B-The nurse asks the patient to rate his pain on a pain scale. C-The nurse asks the patient if he needs to use the bathroom. D-The nurse asks the patient if he has ambulated in the hall today.

D

Under which circumstance(s) should hand washing be repeated? (Select all that apply.) A-Hands touch the sink during hand washing. B-Areas under fingernails remain soiled. C-Cracked areas are noted on the nurse's hands. D-Hands are free of visible soiling. E-Hands are lowered below waist level.

Hands touch the sink during hand washing. Areas under fingernails remain soiled.

An elderly patient is admitted for back surgery. She is now retired but her previous occupation was as a registered nurse. She reports that she is also allergic to morphine and penicillin. She has a history of five laminectomies (back surgeries) resulting from scoliosis as a child. She has three children who visit her. She requires a cane to ambulate. Which factors would be considered high-risk factors for latex allergy? (Select all that apply.) A-Her age. B-History of multiple surgeries as a child. C-Allergy to morphine and penicillin. D-Occupation. E- Use of a cane.

History of multiple surgeries as a child. Occupation.

A nurse reads the following documentation in a patient's electronic health record: 92-year-old female complains of frequent nonproductive cough. States has been taking PO steroids as prescribed. Denies having received pneumonia vaccine. B. Jones, R.N. Based on this information, what factors place this patient at risk for being a susceptible host? (Select all that apply.) A-Hospitalized. B-Nutritional status. C-Age. D-Gender. E-Vaccination status. F- Medical therapy.

Hospitalized. Age. Vaccination status. Medical therapy.

The nurse is preparing an in-service on medical asepsis. Which of the following should be included in the presentation? (Select all that apply.) A-Use sterile gloves if anticipating contact with nonintact skin. B-Artificial nails should be no longer than 0.625 cm (1/4 inch). C-Cough hygiene practices should be followed. D-If worn, fingernail polish should not be chipped. E- Gown and gloves are sufficient PPE for a splash risk. F-Always know a patient's susceptibility to infection.

If worn, fingernail polish should not be chipped. Cough hygiene practices should be followed. Always know a patient's susceptibility to infection.

The nurse is preparing a sterile field. The nurse opens the sterile commercial kit by pulling the outermost flap toward his body, followed by opening the remaining flaps. The nurse touches only the outer edge of the sterile field with his hands. The nurse adds sterile items to the sterile field by placing them on the field at an angle and never allowing the wrapper to touch the field. The nurse pours normal saline form a previously opened bottle in the patient's room into a sterile receptacle without splashing. Which action(s) in preparing a sterile field did the nurse perform incorrectly? (Select all that apply.) A - The nurse correctly prepared the sterile field. B-Opening the outermost flap. C-Touching the outer edge of the sterile field. D- Adding sterile items to the field. E - Pouring a sterile solution

Opening the outermost flap Pouring a sterile solution

Which of the following are symptoms of latex allergy? (Select all that apply.) A-Skin redness. B-Itching. C-Purulent drainage. D-Edema. E-Difficulty breathing. F-Elevated temperature.

Skin redness Itching. Edema Difficulty breathing.

The nurse is preparing a sterile field. Which of the following would be considered contamination of the field? (Select all that apply.) A- Some of the sterile normal saline spills onto the sterile barrier B- Nonsterile items are added to the sterile field C- The nurse prepares the sterile field and leaves the room to get more sterile supplies. D-The nurse prepares the sterile field immediately before the procedure. E- When a sterile item falls off the sterile field, the nurse opens a new sterile item

Some of the sterile normal saline spills onto the sterile barrier Nonsterile items are added to the sterile field The nurse prepares the sterile field and leaves the room to get more sterile supplies.

The nurse manager is reviewing the use of standard precautions with the staff. Which of the following should be included in the review? (Select all that apply.) A-Standard precautions are used to protect you from potential contact with blood and body fluids. B-Standard precautions should be observed in every patient encounter. C-Standard precautions refer only to the use of gloves, not to the use of masks, eye protection, or gowns; these refer to other types of precautions. D-To follow standard precautions, you must wear sterile gloves. E- Standard precautions are used once the type of infection is identified.

Standard precautions are used to protect you from potential contact with blood and body fluids. Standard precautions should be observed in every patient encounter.

The nurse is observing the NAP perform hand hygiene. Which of the following, if performed by the NAP, requires intervention by the nurse? (Select all that apply.) The NAP: A-Applies 3 to 5 mL of antimicrobial soap to hands wet with warm water. B-Takes the patient's blood pressure and leaves the room to document. C-Washes hands with plain soap and water when visibly dirty. D-Puts the patient's socks on, then begins to feed the patient. E-Has an uncovered cut on the back of the nondominant hand. F-Moves the patient's IV pole by the bed and uses hand sanitizer.

Takes the patient's blood pressure and leaves the room to document. Puts the patient's socks on, then begins to feed the patient. Has an uncovered cut on the back of the nondominant hand.

You are washing your hands in a sink with hand faucets. You first turn on the water and regulate the temperature to warm. You increase the water pressure to create a strong spray. You wet your hands, apply 1 teaspoon (5 mL) of soap, and rub your hands together vigorously, creating lather. You interlace your fingers and rub the palms and backs of the hands with a circular motion at least 5 times each. You keep your hands positioned with fingertips down and rinse the hands and wrists thoroughly. You turn off the faucet. You dry your hands with a paper towel. Which step(s) are incorrect? (Select all that apply.) A-The temperature of the water. B-The force of the water. C-The amount of soap used. D-The technique used in lathering. E-The method used to turn off the faucet.

The force of the water. The method used to turn off the faucet.

The NAP complains of his hands hurting and skin being chapped. What would be appropriate suggestions for the NAP? (Select all that apply.) A-Use hand lotion from an individual use container. B-Decrease the frequency of hand hygiene until healed. C-Wear clean latex-free gloves at all times. D-Be sure to rinse and dry hands thoroughly. E-Avoid excessive amounts of soap or antiseptic.

Use hand lotion from an individual use container. Be sure to rinse and dry hands thoroughly. Avoid excessive amounts of soap or antiseptic.