Nurse 202: Quiz #5 Chapter 23: Asepsis and Infection Control
A home health nurse is completing a health history for a client. What is one question that is important to ask to identify a latex allergy for this client?
a) "Have you had any unusual symptoms after blowing up balloons?" b) "Have you ever had an allergic reaction to shellfish or iodine?" c) "Tell me what you use to wash your hands after toileting." d) "When you were a child, did you have frequent infections?" --> "Have you had any unusual symptoms after blowing up balloons?" Explanation: Awareness of a latex allergy is important for safe home care. Nurses need to ask whether clients have experienced any unusual signs or symptoms when blowing up balloons, using latex condoms, or wearing rubber gloves for dishwashing or cleaning.
A pediatric client's caregiver states, "I will never give my child vaccinations." What is the priority nursing response?
a) "Help me understand your thoughts about vaccinations." b) "Transmission of certain diseases is halted with vaccination." c) "Vaccinations prevent disease." d) "Has your child received any previous vaccinations?" --> Help me understand your thoughts about vaccinations." Explanation: Seeking to understand the caregiver's perspective helps the nurse to collect assessment data and create a therapeutic relationship of trust. The nurse could then collect assessment data regarding past vaccines and provide appropriate teaching.
Following insertion of a foley catheter, the nurse instructs the unlicensed assistive personnel (UAP) to remove the sterile gloves by inverting one glove into the other. The UAP states, "Why is that important?" Which response by the nurse is most appropriate?
a) "Inverting gloves makes it easier to get them off throw away." b) "Inverting gloves after inserting a foley prevents the potential for client infection." c) "Inverting gloves prevents any soil on the outside from getting on your uniform." d) "Inverting the gloves entraps the soiled surface and prevents the spread of microorganisms." --> "Inverting the gloves entraps the soiled surface and prevents the spread of microorganisms." Explanation: Inverting the gloves into each other encloses the soiled surface and blocks a potential exit route for microorganisms. The other responses do not get at the core of why the action is important.
A client who has been diagnosed with a cold is upset that antibiotic therapy was not prescribed. Which nursing response is most appropriate?
a) "We can ask the PCP for an antiviral medication." b) "The common cold is a virus and will not respond to antibiotics." c) "Antibiotics have too many side effects anyway." d) "Sometimes antibiotics work for colds and sometimes they do not." --> "The common cold is a virus and will not respond to antibiotics." Explanation: The best response from the nurse is to educate the client about the common cold and how it is treated. An antiviral medication is not effective for the common cold.
The nurse caring for clients at an outpatient clinic determines that which client is at greatest risk for infection?
a) A 2-year-old toddler b) A 12-year-old girl c) An 80-year-old woman d) An 18-month-old infant --> An 80-year-old-woman Explanation: Age, race, sex, and heredity all influence susceptibility to infection. Neonates and older adults tend to be most vulnerable to infection, so the 80-year-old woman is the client most at risk for infection
Which practice is a correct application of infection control practices?
a) A nurse dons a pair of gloves prior to any client contact. b) A nurse ensures that the nurse rinses the hands thoroughly after the application of an alcohol-based handrub. c) A nurse uses an alcohol-based handrub each time that the nurse's hands are visibly soiled. d) A nurse performs hand washing each time the nurse removes a pair of gloves. --> A nurse performs hand washing each time the nurse removes a pair of gloves. Explanation: Hand washing should be performed after the removal of a pair of gloves. Gloves are not required for each and every client contact and visibly soiled hands require a wash with soap and water. Alcohol-based handrubs are not followed by a rinse
The nurse is preparing to don a gown to care for a client requiring contact precautions. When should the nurse don the gown?
a) After entering the client's room b) Before entering the client's room c) After taking the client's pulse d) Before taking the client's pulse --> Before entering the client's room Explanation: The nurse should don the gown before entering the client's room to prevent soiling/contamination of the nurse's clothing with infectious bacteria/viruses and/or the client's blood and body fluids.
After changing the bed linens for a client, the nurse uses an alcohol-based handrub to perform hand antisepsis. What is the proper way to use an alcohol-based handrub?
a) Apply a drop of the handrub, scrub, and rinse with water. b) Rub the product between the hands until they are dry. c) Rub the product between the hands for 5 seconds. d) Distribute the product over the nails and wash with soap. --> Rub the product between the hands until they are dry. Explanation: When decontaminating with an alcohol-based handrub, the nurse should apply about a nickel- to quarter-sized amount of the product to the palm of one hand, distribute the product to cover all surfaces of the hands and fingers, and rub the product between the hands for 15 to 25 seconds until they are dry. The nurse need not rinse the hands with water after using an alcohol rub.
The nurse is caring for a client admitted with tuberculosis (TB). What would be the best action by the nurse?
a) Apply a non-particulate (N-95) respirator when entering the room. b) Wear a mask with face shield during invasive procedures. c) Have the client wear a mask during care. d) Wear a protective gown and gloves with any direct contact. --> Apply a non-particulate (N-95) respirator when entering the room. Explanation: TB is an airborne infection and the nurse should wear a non-particulate mask (N-95) respirator. Gown and gloves would be indicted for infections that are transmitted via direct contact. A mask for face shield would be for infections that are transmitted via droplet. The client does not need to wear a mask during care.
A nurse is working with a 55-year-old woman diagnosed with human immunodeficiency virus (HIV). This nurse also has another client today who has an upper respiratory infection. What is the most important thing the nurse can do to prevent the client with HIV from acquiring the upper respiratory infection?
a) Avoid direct contact with the client. b) Wear a mask and gown in the client's room. c) Wear gloves when touching the client. d) Perform hand hygiene before and after entering the client's room. --> Perform hand hygiene before and after entering the client's room. Explanation: Hand hygiene is the most important way to prevent transmission of infection.
The nurse conducting a hand hygiene in-service determines that the participants need additional education when they state that the use of an alcohol-based handrub is appropriate in which of the following situations?
a) Before direct contact with clients b) When hands are visibly soiled c) After completing a wound dressing d) After direct contact with clients --> When hands are visibly soiled Explanation: Alcohol-based handrubs can be effective for decontaminating a health care worker's hands before and after direct contact with clients and after completion of a wound dressing, EXCEPT when the health care worker's hands are visibly soiled.
The nurse is setting up a sterile field to perform a catheterization when the client touches the end of the sterile field. What would be the nurse's next appropriate action?
a) Change the sterile field, but reuse the sterile equipment. b) Call for help and ask for new supplies. c) Discard the sterile field and the supplies and start over. d) Proceed with the procedure since it was only touched by the client. --> Discard the sterile field and the supplies and start over. Explanation: The nurse's next appropriate action would be to discard the sterile field and the supplies and start over. The client touching the end of the sterile field contaminated the field and the items on the field. The nurse cannot reuse the sterile equipment because the items are no longer sterile.
When preparing to take a client's blood pressure, the nurse notes that the sphygmomanometer is visibly soiled. What is the correct action by the nurse?
a) Cleanse and disinfect the sphygmomanometer b) Use the sphygmomanometer c) Discard the sphygmomanometer in the trash d) Send the sphygmomanometer for sterilization --> cleanse and disinfect the sphygmomanometer
Which of the following clients should the nurse determine is at greatest risk for vancomycin-resistant enterococci (VRE) infection?
a) Client receiving chemotherapy b) Client who had leg surgery c) Client in the ICU for one day d) Client on a short course of vancomycin --> Client receiving chemotherapy Explanation: The nurse should determine that the client receiving chemotherapy is the client at greatest risk for VRE infection due to having a compromised immune system from the chemotherapy.
Which is not appropriate regarding the use of gowns as PPE?
a) Don a gown when splashing. b) use of a new gown each time the nurse enters the room c) use of paper or cloth gowns d) use of one gown per person per shift --> use of one gown per person per shift Explanation: A new gown should be used by the nurse each time the nurse enters the room.
The nurse working with the hospital's infection control team is attempting to decrease the transmission of health care-associated pathogens. Which of the following will be most effective?
a) Encouraging visitors to adhere to isolation precautions b) Incentivizing health care workers to utilize hand hygiene c) Limiting visitors to family members over the age of 18 d) Revising the facility's infection control protocols --> Incentivizing health care workers to utilize hand hygiene Explanation: Most health care-associated pathogens are transmitted via the contaminated hands of health care workers. Therefore, the most effective strategies for decreasing transmission are those that educate or encourage health care workers to utilize effective hand hygiene.
An older adult client has been receiving care in a two-bed room that he has shared with another older, male client for the past several days. Two days ago, the client's roommate developed diarrhea that was characteristic of Clostridium difficile. This morning, the client himself was awakened early by similar diarrhea. The client may have developed which type of infection?
a) Endogenous healthcare-associated b) Exogenous healthcare-associated c) Antibiotic-resistant d) Iatrogenic --> Exogenous healthcare-associated Explanation: The client's suspected infection originated with another person (exogenous) and was contracted in the hospital (healthcare-associated). It was not the result of his treatment (iatrogenic) and C. difficile is not an antibiotic-resistant microorganism.
The nurse is preparing a sterile field for a bedside procedure. During preparation, the client reaches over the field for the water pitcher. What would be the best action by the nurse?
a) Give the client the water pitcher and continue preparation. b) Educate the client on sterile fields and continue preparing for the procedure. c) Remove the supplies from the field and replace with new supplies. d) Discard the supplies and field and prepare a new sterile field. --> Discard the supplies and field and prepare a new sterile field. Explanation: If sterile procedure is disrupted in any way, the nurse must discard all items (including the field) and begin preparing a new sterile field. Reaching over a sterile field would disrupt the sterility of the area.
A lead nurse is removing personal protective equipment after dressing the infected wounds of a client. Which is the highest priority nursing action?
a) Handwashing before leaving the client's room. b) Remove the garments that are most contaminated. c) Make contact between two clean surfaces. d) Make contact between two contaminated surfaces. --> Handwashing before leaving the client's room. Explanation: The most important nursing action is to perform a thorough handwashing before leaving the client's room and before touching any other client, personnel, environmental surface, or client care items.
A nurse is adding a sterile solution to a sterile field and has just opened the bottle according to manufacturer's directions. What is the next step?
a) Hold the bottle inside the 1-inch edges of the sterile field with the label side facing the palm of the hand, then pour from a height of 2 to 4 inches (5 to 10 cm). b) Touch the tip of the bottle to the sterile container to start the flow of the solution, then pour it into the container directly from the top of the container edge. c) "Lip" a new or old bottle of solution before pouring it and hold the solution with the label facing out from a height of 4 to 6 inches (10 to 15 cm). d) Hold the bottle outside the edge of the sterile field with the label side facing the palm of the hand and prepare to pour from a height of 4 to 6 inches (10 to 15 cm). --> Hold the bottle outside the edge of the sterile field with the label side facing the palm of the hand and prepare to pour from a height of 4 to 6 inches (10 to 15 cm). Explanation: The correct next step for adding a sterile solution is as follows: hold the bottle outside the edge of the sterile field with the label side facing the palm of the hand and prepare to pour from a height of 4 to 6 inches.
The nurse is disposing of an old dressing that is saturated with a client's blood. How should the nurse dispose of the dressing?
a) In the client's trash container b) With the double-bag technique c) In the sharps container d) In a bag marked "biohazards" --> In a bag marked "biohazards" Explanation: The nurse should dispose of a blood dressing in a bag marked biohazards. In fact, all trash that contains liquid or semiliquid blood or potentially infective material should be disposed of in a bag marked "biohazards."
A nurse is in charge of care for a client who has MRSA. Which of the following is an accurate guideline for using transmission-based precautions when caring for this client?
a) Keep visitors 3 feet (1 m) from the client. b) Place the client in a private room that has monitored negative air pressure. c) Wear gloves whenever entering the client's room. d) Use respiratory protection when entering the room. --> Wear gloves whenever entering the client's room. Explanation: Contact precautions are used for clients who are infected or colonized by a microorganism that spreads by direct or indirect contact, such as MRSA, VRE, or VISA. Gloves should be worn when entering the client's room. Use of negative air pressure and respiratory protection are appropriate with airborne precautions.
The nurse is caring for a client who has been placed in strict isolation. Which nursing action is appropriate?
a) No special precautions are required. b) Remove fresh fruit from the room. c) Allow many family members to visit at once. d) Deliver flowers and balloons to the room. --> Remove fresh fruit from the room. Explanation: Fresh fruit and flowers can carry pathogens and chemicals to which the client should not be exposed. The number of visitors should be controlled to prevent exposure to multiple infection opportunities.
A family member with a mild upper respiratory infection comes to visit a client in a long-term care facility. What is the appropriate nursing intervention?
a) Offer the family member a mask, explaining its use. b) Allow the family member to visit, but only for 5 minutes. c) Let the family member know that the client cannot be visited. d) Welcome the family member into the client's room. --> Offer the family member a mask, explaining its use. Explanation: Visitors with respiratory infections need to wear a mask until their symptoms have subsided. The other answer options are incorrect use of infection control for this client.
A nurse follows surgical asepsis techniques for inserting an indwelling urinary catheter in a client. What is an accurate guideline for using this technique?
a) Open sterile packages so that the first edge of the wrapper is directed toward the nurse. b) Consider the outer 3-inch edge of a sterile field to be contaminated. c) Hold sterile objects above waist level to prevent inadvertent contamination. d) Consider the outside of the sterile package to be sterile. --> Hold sterile objects above waist level to prevent inadvertent contamination. Explanation: Holding a sterile object above waist level ensures the object is kept in sight and prevents accidental contamination. The outside of the sterile package and the outer 1 inch of a sterile field are contaminated.
The nurse is caring for a client who has active tuberculosis (TB) and is in Airborne Precautions. The primary care provider orders a computed tomography (CT) examination of the chest. Which action by the nurse is appropriate?
a) Question the need for the examination because the client must remain in Airborne Precautions. b) Place a surgical mask on the client and transport to the CT department at the specified time. c) Request that the examination be done at the bedside. d) Notify the CT department in advance so other clients and staff can be removed from the area. --> Cleanse and disinfect the sphygmomanometer Explanation: The nurse should cleanse and disinfect the sphygmomanometer. A sphygmomanometer is another name for a blood pressure cuff.
A patient has sought care because of a knee wound that appears to have become infected. Which of the following processes is a component of the cellular stage of inflammation that occurred earlier in his body's response to infection?
a) Release of histamine b) Production of antibodies c) Constriction of the small blood vessels near the wound d) Migration of leukocytes to the area of the wound --> Migration of leukocytes to the area of the wound Explanation: During the cellular stage of inflammation, white blood cells (leukocytes) move quickly into the area. Small vessel constriction and histamine release are associated with the vascular stage of inflammation while antibody production is characteristic of the immune response to infection.
A nurse is caring for a 55-year-old post-operative client. The client returns to the ICU after surgery intubated and mechanically ventilated with a Salem sump nasogastric tube, a Foley catheter, and a PICC line in place. Based on the nurse's knowledge of the most common hospital-acquired infections, which apparatus is most important to remove first?
a) Salem sump nasogastric tube b) PICC line c) Endotracheal tube d) Urinary catheter --> Urinary catheter Explanation: Urinary catheters account for the highest percentage (26%) of hospital-associated infections.
To eliminate needlesticks as potential hazards to nurses, the nurse should:
a) Slide the needle into the cap and deposit it in a puncture-proof plastic container. b) Place the uncapped needle on a tray and carry it to the medicine room for disposal. c) Stick the uncapped needle into a Styrofoam block and deposit in a plastic container. d) Immediately deposit uncapped needles into puncture-proof plastic container. --> Immediately deposit uncapped needles into puncture-proof plastic container. Explanation: All uncapped needles should be placed in puncture-proof plastic units immediately after use.
What is an accurate guideline for the use of PPE?
a) Substitute personal glasses for protective eyewear, if desired. b) When wearing gloves, work from "dirty" areas to "clean" ones. c) Put on PPE after entering the client's room. d) Replace gloves if they are visibly soiled. --> Replace gloves if they are visibly soiled. Explanation: If gloves become torn or heavily soiled, they should be removed and replaced. PPE should be put on before entering the client's room and glasses should not be substituted for protective eyewear. Work should progress from "clean" areas to "dirty" areas.
A client has an inguinal hernia repair and later develops a methicillin-resistant Staphylococcus aureus (MRSA) infection. What is the most important factor to prevent this infection?
a) Surgical asepsis b) Increased vitamin C c) Increased T cells d) Decreased antibiotics --> Surgical asepsis Explanation: Clients are at risk for healthcare-associated infections when the health care staff does not follow safety guidelines. Medical and surgical asepsis are the primary safety interventions for preventing disease in the health care environment.
Which of the following masks should the nurse don when caring for a client with tuberculosis?
a) Surgical mask b) No mask is needed c) Low-efficiency particulate air (LEPA) d) Filtered respirator --> Filtered respirator Explanation: When caring for a client with tuberculosis, the nurse should don a filtered respirator mask to filter the inspired air.
The nurses on a busy surgical ward use hand hygiene when caring for postsurgical patients. Which action represents the appropriate use of hand hygiene?
a) The nurse refrains from using hand moisturizer following hand hygiene. b) The nurse uses gloves in place of hand hygiene. c) The nurse uses hand hygiene instead of gloves when in contact with blood. d) The nurse keeps fingernails less than ¼ inch long. --> The nurse keeps fingernails less than ¼ inch long. Explanation: The nurse needs to keep fingernails less than ¼ inch long. Gloves should never be used in place of hand hygiene. Gloves should always be worn when the nurse is in contact with blood.
The nurse is teaching a new nurse about preparing a sterile field. Which action made by the new nurse would indicate further teaching is required?
a) The sterile field is set up at waist level. b) Direct visualization of the sterile field is maintained. c) The new nurse touches 1.5 inches from the outer edges. d) The top flap of the package is opened away from the new nurse's body. --> Place a surgical mask on the client and transport to the CT department at the specified time. Explanation: Transport clients in Airborne Precautions out of the room only when necessary and place a surgical mask on the client, if possible.
The nurse is donning a pair of sterile gloves. The nurse correctly dons the first glove, but inadvertently inserts the thumb and index finger into the thumb hole of the second glove. The glove remains intact. Which action is most appropriate?
a) Use only the correctly gloved hand to perform the sterile procedure while making sure the other hand does not contaminate the sterile field. b) Leave both the thumb and finger in the thumb hole and perform the procedure to the best of the nurse's ability. c) Don a second pair of sterile gloves over the first pair. d) Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole. --> Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole. Explanation: It is appropriate to adjust the gloves by touching sterile surface to sterile surface.
When a nurse picks up a client's contaminated tissue without gloves and fails to wash the hands sufficiently, the nurse provides for the client's organisms to be spread by which type of transmission?
a) Vector b) Vehicle c) Contact d) Airborne --> Contact Explanation: Direct contact involves body surface-to-body surface contact, causing the physical transfer of organisms between an infected or colonized host and a susceptible host.
The nurse has completed an intervention with a client. There is no visible soiling on the nurse's hands. Which technique is recommended by the Centers for Disease Control (CDC) for hand hygiene?
a) Wash hands with soap and water, followed by an alcohol-based hand rub. b) Wash hands with soap and hot water. c) Do not wash hands; apply clean gloves. d) Decontaminate hands using an alcohol-based hand rub. --> Decontaminate hands using an alcohol-based hand rub. Explanation: Alcohol-based hand rubs can be used if hands are not visibly soiled
Which client presents the most significant risk factors for the development of Clostridium difficile infection?
a) a 44-year-old client who is paralyzed and whose coccyx ulcer has required a skin graft b) an 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis c) A 30-year-old client who has recently contracted human immunodeficiency virus (HIV) after engaging in high-risk sexual behavior d) A client with renal failure who receives hemodialysis three times weekly --> an 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis Explanation: Old age and recent, long-term antibiotic therapy are significant risk factors for C. difficile infection. These supersede the risks posed by recent HIV infection, skin grafts, and hemodialysis.
For which client would the use of standard precautions alone be appropriate?
a) a client with diphtheria who needs p.m. care b) an incontinent client in a nursing home who has diarrhea c) a client with TB who needs medications administered d) a child with chickenpox who is treated in the emergency room --> an incontinent client in a nursing home who has diarrhea Explanation: Standard precautions apply to blood and all body fluids, secretions, and excretions, except sweat. transmission-based precautions
The nurse is caring for a client with tuberculosis. Which precautions will the nurse select for this client?
a) airborne b) droplet c) contact d) standard --> airborne Explanation: Tuberculosis is transmitted via the air. Therefore, airborne precautions are required. Standard, droplet, and contact precautions will not be selected by the nurse for a client who has tuberculosis.
The nurse observes an unlicensed assistive personal (UAP) collecting a urine specimen from a client with Staphylococcus aureus infection. Which action by the UAP would require the nurse to intervene?
a) asks the client to state name and date of birth b) removes gloves and walks out of the room c) applies a mask with face shield d) performs hand hygiene before donning gloves --> removes gloves and walks out of the room Explanation: Personal protective equipment (PPE), including gloves, gowns, masks, and googles, are used a barrier to prevent direct contact with blood, body fluids, secretions, and excretions. PPE is also used to protect clients from microorganisms transmitted by nursing personnel when performing procedures or care. Hand hygiene should be performed before and after wearing gloves and direct contact with clients.
When is hand hygiene with an alcohol-based rub appropriate, as opposed to using handwashing?
a) before eating and after using the restroom b) when hands have been in contact with blood or body fluids, but there is no visible soiling c) when hands are not visibly soiled d) when hands have been in contact with blood or body fluids --> when hands are not visibly soiled Explanation: Alcohol-based hand rubs may be used if hands are not visibly soiled, or have not come in contact with blood or body fluids. They should be used before and after each client contact, or when in contact with surfaces in the client's environment. Handwashing is required before eating or after using the restroom.
A client with HIV is the:
a) carrier. b) specificity. c) pathogen. d) virulence. --> Carrier Explanation: Clients may become infected from people who have active disease, people in the incubation portion of their disease, or people who harbor pathogens but have no symptoms of disease.
While assessing a client admitted with a transmissible spongiform encephalopathy, what finding might the nurse observe?
a) difficulty breathing b) unsteady gait c) distended abdomen d) redden, circular rash --> unsteady gait Explanation: Transmissible spongiform encephalopathy is caused from mutated prions. The mutated prions cause holes in the brain and leave a spongy appearance. The changes in the brain tissue lead to uncoordinated movements
The nurse is caring for a client who became very ill after ingesting seafood. How will the nurse document this condition?
a) noncommunicable disease b) communicable disease c) infectious disease d) contagious disease --> noncommunicable disease Explanation: A noncommunicable disease is caused by food or environmental toxin. Infections diseases, communicable disease, and contagious disease do not describe food poisoning.
A nursing student is donning sterile gloves to perform routine tracheostomy care for a client. Which behavior by the student would require immediate intervention from the instructor?
a) picks up the glove at the folded edge with the thumb and forefinger b) reaches down to the bed to pick up a sterile drape c) washes hands for 20 seconds with soap and water d) stretches the glove over the hand without touching the unsterile area --> reaches down to the bed to pick up a sterile drape Explanation: The sterile gloves should always stay above waist level. Reaching down to the bed could create contamination to the sterile field and the student should be stopped and asked to don sterile gloves again.
A nurse who is taking the vital signs of a client with acute diarrhea is ordered to attend to another client. What is the highest priority nursing action the nurse must perform before leaving the client's room?
a) placing one bag of contaminated items within another b) removing personal protective equipment that is most contaminated first c) thorough handwashing d) spraying of disinfectant --> thorough hand washing
The nurse is preparing discharge instructions for a family member who will be caring for a client with an abdominal incision. Which concept should be the priority in the teaching plan?
a) sterile technique b) signs of healing c) putting on gloves d) hand washing --> hand washing
The nurse who is caring for a client in contact isolation is preparing to conduct an assessment. How will the nurse listen to the client's heart?
a) stethoscope that remains in the client's room b) stethoscope that hangs outside the client's room c) stethoscope that has been purchased by the client d) stethoscope belonging to the nurse --> stethoscope that remains in the client's room Explanation: A dedicated stethoscope and blood pressure cuff should remain in the client's room when a client has been placed in contact isolation. Therefore, the nurse would not use the nurse's personal stethoscope, or one that hangs outside the client's room or that was purchased by the client.
Surgical asepsis is defined as:
--> absence of all microorganisms. Explanation: Surgical asepsis refers to sterile technique and indicates procedures used to eliminate any microorganisms.
The nurse is aware that many products in the hospital have the potential to contain latex. Which piece of protective equipment is most likely to contain latex?
a) Surgical masks b) Goggles c) Pillows d) Gowns --> Surgical masks Explanation: Surgical masks may contain latex.Pillows, goggles and gowns likely do not contain latex.
The nurse is preparing to don sterile gloves for a procedure that requires surgical asepsis. Place the following steps, in the correct order, that the nurse should take when donning sterile gloves. All options must be used.
In this order: 1) Carefully open the inner package taking care not to touch the inner surface of the package or the gloves. 2) With the thumb and forefinger, grasp the folded cuff of the glove, insert fingers while pulling the glove over thee hand. 3) Place the fingers of the gloved hand inside the cuff of the remaining glove and insert the fingers while stretching it over the hand. 4) Adjust gloves on both hands if necessary, touching only sterile areas with other sterile areas.
The nurse is preparing to perform hand washing. Arrange the steps in the correct order.
Turn on the faucet and adjust force and temperature of the water. Wet the hand and wrist areas. Apply soap product. Wash the palms and back of the hands for at least 15 seconds. Pat hands dry with a paper towel. Turn the faucet off with a paper towel.
When preparing a sterile field, the nurse notes that bottle of sterile saline was opened 48 hours ago and is half full. What should the nurse do?
a) discard the bottle b) finish the contents of the bottle c) shake the bottle several times d) lip the opening of the bottle twice --> discard the bottle Explanation: Once a bottle of sterile saline is open, the contents must be used within 24 hours of opening. Lipping the opening of the bottle is appropriate, but contents in the bottle are expired.
Which nursing action is a component of medical asepsis?
a) drawing blood from a central line b) handwashing after removing gloves c) insertion of an indwelling urinary catheter d) insertion of an intravenous catheter --> handwashing after removing gloves Explanation: Medical asepsis (clean technique) involves procedures and practices that reduce the number and transfer of pathogens. Medical asepsis procedures include performing hand hygiene and wearing gloves. Surgical asepsis (sterile technique) includes practices used to render and keep objects and areas free from microorganisms (insertion of urinary or intravenous catheters).
The nurse suspecting that a client has an infected surgical wound should assess for which sign? Select all that apply.
• Pain • Exudate • Swelling • Redness Explanation: Cardinal signs of infection include redness (heat), swelling, pain, and loss of function. As leukocytes and neutrophils enter the area, exudate made up of fluid, cells, and inflammatory by-products may be released by the wound. Warmth and heat at the site versus coolness are a sign of infection.
The nurse is preparing a client who is in droplet isolation for transport to radiology. What is the appropriate nursing intervention?
• facilitating interdepartmental coordination about the transport • placing a clean sheet onto the stretcher that the client will be transported upon • ensuring that the client has a mask on • reminding transporter to utilize droplet precautions Explanation: The nurse will provide interdepartmental coordination, use methods to prevent the spread of pathogens (such as lining the surface of the stretcher with a sheet to protect the surface from direct contact), and ensure that the client is wearing a mask before being transported. The nurse will not remove the client's mask for transport.
