Taylor Videos: Asepsis and Wound Care

When packing a wound with a saline-moistened dressing, what is placed over the wound to prevet contamination?

ABD pad

When irrigating a wound using sterile technique, how high above the wound should the nurse hold the tip of the irrigating syringe?

At least one inch.

The nurse has prepared a sterile field with the necessary sterile supplies. The nurse begins to perform the care and realizes that an item is missing

Call someone to bring in the necessary them t the patient's room.

Which of the following assessment techniques would the nurse use to assess a pressure ulcer?

Inspection and palpation

The nurse is collecting a culture form a patient's wound and removes the dressing form the wound. What would the nurse do next?

Put one clean gloves

Thee nurse is putting on sterile gloves, Which of the following would be important to keep in mind?

The hands should remain above waist level at all times

The nurse is performing a sterile dressing change. Which of the following would require the nurse to put on a new pair of gloves?

The nurse touches the patient's skin with one hand.

When removing gloves, which of the following would the nurse do?

Using the gloved dominant hand, grasp the glove of the non-dominant hand near the cuff on the outside.

When irrigating a patient's wound, the nurse pours irrigation solution form the bottle into a sterile container. Which of the following is a recommended action for this step in the procedure?

Date and reuse leftover irrigation solution within 24 hours.

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

Dehiscence

The nurse is perforiming hand washing using soap and water. After rinsing the hands under running water, which of the following would the nurse do next?

Dry the hands with a paper towel.

The nurse is irrigating a patient's wound. What action would the nurse take after the irrigation solution from the wound flows out clear?

Dry the surrounding skin with a sterile gauze sponge and place a sterile dressing on the wound.

The nurse has finished cleaning a patient's surgical wound. What would be the nurses' next action the procedure?

Dry the wound with a gauze sponge.

The nurse is caring for a patina with a Hemovac drain in place after surgery. How often would the nurse check the drain status?

Every 4 hours.

The nurse has finished cleaning a patient's surgical wound ash has applied a dry, sterile dressing. How often would the nurse check the would dressing?

Every shift

The nurse is positioning a patient with pressure ulcer to prepare to irrigate the wound. How would the nurse direct the flow of irrigation solution over the wound?

From the upper end of the wound to the lower end.

The nurse is caring for a patient with an unstageable pressure ulcer. Which of the following is a characteristic of this stage of pressure ulcer development?

Full-thickness tissue loss with the base of the wound bed covered by slough.

Which of the following would the nurse remove first when removing personal protective equipment

Gloves

Which of the following would least likely require a nurse to change sterile gloves?

Gloves touch a sterile dressing

The nurse is required to wear a gown, gloves, goggles, and mask as personal protective equipment (PPR) when caring for an assigned patient when caring for an assigned patient. Which of the following would the nurse put on first?

Gown

The nurse is assessing a patient's pressure ulcer for sings of healing. Which of the following is a sing that the healing process as begun?

Granulation tissue

When removing soiled gloves, which of the following would the nurse do first?

Grasp the outside of one glove with the opposite gloved hand.

A group of students are studding for an examination on the principles of asepsis. The students demonstrate understanding when they identify which of the following as the most effective way to prevent spread of microorganisms?

Hand hygiene.

Caring for a patient with a stage III pressure ulcer, the nurse measures the depth of the wound. Which of the following is a recommended action for this procedure?

Insert a sterile applicator gently into the wound at a 90-degree angle.

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

"Turning a back to a sterile field maintains the sterility of the field."

When adding sterile items to a sterile field, the nurse would drop sterile item form which hight?

6 inches

The nurse is irrigating a patient's wound using sterile technique. When directing the irrigating solution into the wound, what does the nurse use to collect the solution

A sterile basin

Which of the following patients would be at greatest risk for developing a pressure ulcer?

An adult patient who is comatose

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

Assess for pain, shortness of breath, shortness of breath, and abdominal pressure.

The nurse is adjusting a patient bed to perform wound care. What would be a comfortable working height at which the nurse would place the bed?

At elbow height

A group of nursing students are reviewing information about asepsis in preparation for a test. The students demonstrate understanding of the topic when they identify which of the following as the primary rationale for asepsis?

Break the chain of infeciton

When preparing a sterile field, which of the following would be appropriate to do first?

Check the packages for expiration date

The nurse is collecting a wound culture form a patient's puncture wound. Which of the following would be the nurse's first step in the procedure?

Clea the wound

The nurse is cleaning a patient's wound that has a drain. What should the nurse do with the drain during this procedure

Clean around the drain

The nurse is caring for a patient wound that has a Hemovac drain in place. How would the nurse care for the sutures at the drain site?

Clean the sutures with a gauze pad moistened with normal saline

The nurse is packing a patient pressure ulcer with a saline-moistens dressing. Which of the following is a recommended step in this procedure?

Clean the would and dry the surrounding skin with sterile gaze dressings.

The nurse is preparing a sterile field using a pre-packaged kit. After performing hand hygiene, which of the following would the nurse do

Confirm the patient's identity

There is some question about the use of appropriate transmission-based precautions when caring for patient. Some of the nurses are wearing personal protective equipment and others are not. Which of the following wold be most appropriate?

Consulting the agency' infection control manual

The nurse, assessing a patient for pressure ulcers, notices that these is stable eschar on the heels of the patient. What nursing intervention would be performed in this situation

No nursing intervention is needed in this situation.

The nurse cairn for a patient's wound knows that which one of the following condition is caused primarily by carelessness in practicing asepsis when providing wound care?

Nosocomial infections

The nurse is preparing to add a sterile dressing to a sterile filed. The nurse contaminates the item as the time falls at which locations?

On the one-inch border.

The nurse is preparing to put on a pair of sterile gloves. When opening the inner package, which of the following would the nurse do first?

Open the top flap

When putting on the second sterile glove, the nurse places the gloved thumb on which location?

Outward away form the gloved hand

The nurse has gathered several individually packages dressings for a sterile dressing change. When adding these dressing to the sterile field, which of the following would the nurse do?

Peel the edges apart with both hands

The nurse is cleaning a patient's surgical wound. Which of the following steps would the nurse perform first?

Place a biohazard bag at a convenient location for use during the procedure.

The nurse is preparing a sterile field and needs to add an agency-wrapped item to the field. Which action would be most appropriate?

Reach around the package tenfold the flaps

The nurse is washing his or her hands using soap and water. Which of the following would be done?

Remove any jewelry

While performing a sterile dressing change, the nurse inadvertently contaminates the right hand which action by the nurse would be most appropriate?

Replace the current gloves with a new set of sterile gloves

The nurse is changing the dressing on a patient's surgical wound. After the old dressings removed, the nurse notices that the patient's skin is red and blistered where the dressing had been secured with ape. Which of the following would be an appropriate action y the nurse?

Replace the dressing with a larger one.

The nurse is collecting a culture form a patient's wound. When inserting the swab, what type of action would the nurse use to collect the specimen?

Rolling motion

The nurse has created a sterile field with sterile dressings in preparation for a patient's wound care. While getting ready to apply a dressing, the patient moves his arm and touches the sterile field. Which action by the nurse would be most appropriate?

Set up an entirely new sterile field

The nurse has put on one sterile glove and is preparing to put on the other. Which of the following wold be appropriate?

Slide the gloved fingers under the cuff of the second glove.

The nurse is assessing patient's pressure ulcer and notes that there is full-thickness tissue loss with undermine, but no bone, tendon, or muscle is exposed. What stage of pressure ulcer development has occurred?

Stage III

The nurse has prepared a sterile field using a pre-package kit. Which of the following would be important for the nurse to kip in mind?

The field is contaminated if it is out of the nurse's site.

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

The gloves ends extend to cover the gown's cuffs.

When opening a pre-packaged kit to prepare a sterile field, which of the following would be most important to keep in mind?

The inner surface of the outer wrapper is considered sterile.

The nurse is opening a package containing a sterile drape to establish a sterile field. Which of the following would indicate that the nurse ha contaminated the sterile drape?

The nurse allows the drape to touch his or her body.

The nurse determines that the sterile field has been contaminated when which of the following occurs?

The nurse turns his or her back to the field

The nurse is planning to use a pre-packaged kit to prepare a sterile field. Which of the following would be of least importance in ensuring the sterility of the kit?

The outer wrapper is disposed in an appropriate receptacle.

The nurse is preparing to clean a patient's surgical wound. What would the nurse assess first before being the procedure

The patient's comfort and effectiveness of pain medicaiton.

An nursing instructor is preparing to teach a class on asepsis and hand hygiene. Which of the following would the instructor include?

The sink is considered a contaminated surface

A group of student s are demonstrating the skill for hand washing. Which of the following indicated need for additional practice?

The students use hot water to complete the and washing skill.

A studient is demonstrating the technique for hand hygiene using an antiseptic hand rub. Which of the following would indicate the need for additional practice?

The sudden applies the product to the back of the hand.

The nurse is preparing to put on sterile gloves. When putting on the first glove, the nurse grasps folded cuff of the first glove with which f the following?

Thumb and forefinger

After cleaning a patient's surgical wound, the nurse applies a layer of dry, sterile dressing over the wound site, and then applies a second later. What is the purpose of the first layer of gauze?

To act as a wick for drainage.

The nurse is collecting a wound culture on a patient prior to staring antibiotic therapy. What is the rationale for performing a culture?

To direct future treatment.

What is the rationale for using strict aseptic technique when obtaining a wound culture?

To identify the pathogen causing the infection

The nurse is caring for patent with a pressure ulcer 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?

To promote moist wound healing and protect the wound form contamination and trauma.

After setting up a sterile field putting on sterile gloves, the nurse prepares to clean a patient's surgical wound. In what direction would the nurse clean the wound?

To to bottom

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 of the following would the nurse do first?

Unfasten the gown at the waist.

The nurse is removing a grown after providing care to a patient. Which of the following wold the nurse do first?

Unfasten the ties at the neck and back

When setting up a sterile field, the nurse opens a sterile package prepared by the facility. Which following would the nurse do first?

Unfold the top flap away from the body

The nurse is teaching the student nurse how to care for a patient's pressure ulcer. What would the nurse state was the main cause of pressure ulcer development?

Unrelieved pressure that damages underlying tissues

When performing hand hygiene using an antiseptic hand rub, the nurse would continue to rub for how long?

Until the antiseptic has evaporated form the skin.

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

Use a gauze pad to clean the outlet

The nurse is changing the dressing on a patient's surgical wound and notices that part of the dressing is sticking to the underlying skin.

Use a small amounts of sterile saline to loosen and remove the dressing

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

Using Montgomery straps nested of adhesive tape to hold the dressing in place.

When washing hands using soap and water, which of the following would be the most appropriate

Using a rubbing, circular motion

The nurse would appropriately choose an antiseptic hand rub to perform hand hygiene for which situation?

When hands are not visibly soiled

The nurse is irrigating a patinet's pressure ulcer. How would the nurse know when to stop irrigation the wound?

When the solution form the wound flows out clear.

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

With a safety pin, secure the drain to the patient's gown below the wound.