Sterile Technique

When removing soiled gloves, which should the nurse do first? A. Grasp the outside of one glove with the opposite gloved hand. B. Slide the fingers under the glove at the wrist. C. Turn the glove inside out as it is being pulled off. D. Peel the glove off over the other glove

A When removing soiled gloves, the nurse would grasp the outside of one glove with the opposite gloved hand and peel it off, turning the glove inside out as it is pulled. The removed glove is held in the remaining gloved hand. The nurse would then slide the fingers of the ungloved hand under the remaining glove at the wrist and peel off the glove over the first glove, containing one glove inside the other.

The nurse has put on one sterile glove and is preparing to put on the other. What is the next step in donning the second glove? A. Use the fingers to grasp the edges of the cuff of the second glove. B. Use the thumb and index finger to grasp the cuff. C. Hold the second glove in the palm of the gloved hand. D. Slide the gloved fingers under the cuff of the second glove.

Slide the gloved fingers under the cuff of the second glove. After putting on the first glove, the nurse would slide the fingers of the gloved hand under the cuff of the second glove, thereby maintaining sterility, and insert the hand into the glove. When putting on the first glove, the nurse would use the thumb and index finger to grasp its cuff. Holding the second glove in the palm of the gloved hand would be inappropriate. Using the fingers to grasp the edges of the cuff of the second hand could cause contamination of the first gloved hand.

The nurse is putting on sterile gloves. Which principle would be important to keep in mind?

The hands should remain above waist level at all times.

The nurse has created a sterile field with sterile dressings in preparation for a client's wound care. While getting ready to apply a dressing, the client moves his arm and touches the sterile field. Which action by the nurse would be most appropriate? Set up an entirely new sterile field. Add new sterile dressings to the sterile field. Replace any items that moved with new ones. Ask the client if he touched anything.

set up new sterile field

Which should be documented by the nurse? The fact that the nurse donned gloves two different times during a procedure. The fact that sterile technique was used for a given procedure. The specific items that the nurse transferred into a sterile field. The fact that the nurse washed her hands before a procedure.

sterile technique was used The fact that sterile technique was used for a given procedure should be documented, but the other items listed do not need to be documented, as they are standard procedure.

The nurse needs to place gauze from a wrapped item into the sterile field. Which action does the nurse take? Extend the sterile field by laying the open package beside it. Remove the gauze from the package with one sterile hand. Lay the item in an open package on the 1-in (2.5-cm) border. Drop the item from 6 in (15 cm) above the sterile field.

Drop the item from 6 in (15 cm) above the sterile field.

While removing gloves after performing client care, what action does the nurse take? Discard each glove separately into the waste receptacle. Ensure the skin of the hands does not touch the outside surface of the glove. Wrap the discarded gloves inside the sterile field for waste disposal. Use hand sanitizer on the surface of the gloves prior to glove removal.

Ensure the skin of the hands does not touch the outside surface of the glove.

Which statement best explains the rationale for bringing an extra pair of sterile gloves into an adult client's room before preparing for a sterile procedure? If the first pair is contaminated and needs to be replaced, the nurse does not need to leave the room for a new pair If another staff member enters the room and volunteers to assist, sterile gloves are immediately available. An additional pair will be needed if the client reveals a previously undisclosed sexually transmitted infection. Unfamiliar supplies and equipment may frighten the client, so demonstrating the use of sterile gloves before the procedure may make the client more compliant.

If the first pair is contaminated and needs to be replaced, the nurse does not need to leave the room for a new pair

When adding sterile items to a sterile field, the nurse would drop the sterile items from which height?

6 in (15 cm)

What action does the nurse perform to remove gloves after performing a sterile procedure? A. Invert the glove as it is removed. B. Pull the glove off starting at the fingers C. Place the first removed glove in the waste. D. Lay the first removed glove in the sterile field.

A This action decreases contamination risk during removal. Pulling the gloves off from the fingertips is a less clean manner in which to dispose of the gloves and can lead to contamination to the nurse. Gloves are not laid into the sterile field, but directly disposed of. The nurse disposes of the gloves together, not one at a time.

The nurse puts on sterile gloves in preparation for a sterile central line dressing change. The nurse realizes that the bed is too low to complete the procedure adequately. What action does the nurse take?

Ask someone to raise the bed The nurse can ask someone else to raise the bed. This may be the client or anyone in the room capable of assisting. Other than this, the nurse would need to call someone to come in and raise the bed or change the gloves for new sterile gloves. Once the nurse uses any part of the sterile glove to touch a non-sterile surface, that glove is no longer sterile. It makes no difference if the nurse removes the sterile gloves; once they are removed they cannot be reused safely. Placing clean gloves over the sterile gloves destroys the sterility.

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. Don a second pair of sterile gloves over the first pair. B. Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole. C. Use only the correctly gloved hand to perform the sterile procedure while making sure the other hand does not contaminate the sterile field. D. Leave both the thumb and finger in the thumb hole and perform the procedure to the best of the nurse's ability.

B Rationale: It is appropriate to adjust the gloves as long as the nurse only touches sterile surface to sterile surface. Leaving the thumb and finger in the thumb hole or only using the correctly gloved hand to perform the sterile procedure would not be appropriate, nor would donning a second pair of gloves, in this case.

The nurse opens the package of sterile gloves using the interior side folds, and the package will not open fully for the nurse to reach the gloves. What action does the nurse take? A. Slide the gloves out of the package. B. Obtain a new pair of sterile gloves. C. Open the top and bottom folds completely D. Reach under the package folds to open.

C When the inside folds of the glove package will not open correctly, the nurse might not have fully opened the top and bottom folds of the package. When this occurs, the package keeps closing back in on itself, making it difficult to put the sterile gloves on correctly. Therefore, opening the bottom and top fold completely allows the interior side folds to open as needed. Sliding the gloves out of the package leads to the gloves contacting the edge of the sterile package, which is not considered sterile—just like any sterile field edge. Reaching under the package is not a useful action, and there is no reason to obtain new gloves yet.

While donning sterile gloves for a client's dressing change, the nurse rips the cuff while pulling it over a wristwatch. What is the appropriate nursing action? A. Place a new sterile glove over the ripped glove. B. Use the ripped glove for nonsterile actions. C. Obtain a new pair of sterile gloves. D. Continue with the dressing change.

C The nurse must change gloves. The ripped glove is not sterile, nor is the wrist which should be covered by the cuff. The intact glove may also be contaminated because the fingers were in the cuff as it ripped.

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. What action would be appropriate?

Call someone to bring in the necessary item to the client's room. Won't have to set up a whole new sterile field.

When preparing a sterile field, which action would be appropriate for the nurse to take first? Place the work surface at chest height. Put on sterile gloves. Open any sterile items to be used. Check the packages for expiration date.

Check expiration date

What action should the nurse take when changing a sterile dressing on a central venous access device? Place sterile gloves on before removing the existing dressing. Cleanse the central venous access device site while wearing sterile gloves. Position the sterile dressing supplies on the table between the nurse and client. Leave the bed in a low position if the side rail will need to be lowered.

Cleanse the central venous access device site while wearing sterile gloves. Rationale: The nurse performs site care after applying sterile gloves, including cleansing the site with an antiseptic. Sterile gloves are not needed to remove the existing dressing, and, if used, the gloves must be discarded prior to completing site care and the dressing change. The nurse does not need to leave the bed in the lowest position while at the bedside. The sterile supplies are placed to the side of the nurse so that the nurse does not have to reach across the sterile field to perform care.

The nursing instructor observes the nursing student removing sterile gloves. Which action indicates the need for further teaching? A. The student rolls gloves into each other during removal for disposal in the waste can. B. The student reaches under the glove on one hand to peel the glove off of the other hand. C. The student uses one gloved hand to grab the outside surface of the other glove. D. The student pulls the gloves off starting with the fingertips prior to removal.

D Grabbing the outside surface of the non-dominant glove with the glove on the dominant hand ensures the gloves are removed smoothly without contaminating the room, surfaces, or the nurse's hands. The nurse ensures that the dirty side of the glove does not touch the skin and that any contaminants are contained to the glove's outer surface. The other actions are correct. The student does use one gloved hand to grab the outside surface of the other, reaches under the glove on one hand to peel the glove off the other hand, and rolls gloves into each other during removal for disposal in the waste can.

When removing soiled gloves, which action should the nurse take? A. Grab the gloved dominant hand at the wrist using the fingers of the non-dominant hand to invert the glove. B. Slide the fingers of the gloved non-dominant hand between the skin and glove of the dominant hand. C. Pull on the fingertips of the gloved non-dominant hand using the fingers of the gloved dominant hand. D. Using the gloved dominant hand, grasp the glove of the non-dominant hand near the cuff on the outside.

D When removing soiled gloves, the nurse would use the gloved dominant hand to grasp the opposite (non-dominant) glove near the cuff end on the outside and remove it by pulling it off while inverting it so that the contaminated area remains on the inside. The nurse would then slide the fingers of the now ungloved hand between the remaining glove and the wrist, pulling it off while inverting it, to keep the contaminated area on the inside and secure the first glove inside the second.

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

Outward away from the gloved hand

The nurse has gathered several individually packaged dressings for a sterile dressing change. When adding these dressings to the sterile field, which action would the nurse take? Peel the edges apart with both hands. Pull the top cover off at an angle. Cut the package open with sterile scissors. Tear open the package across the top.

Peel the edges apart with both hands

The nurse uses a small amount of sterile solution from a large, multiuse bottle to moisten gauze in a sterile field. What technique does the nurse use? Pour the liquid onto gauze on the sterile field until the gauze is moist. Pour the liquid into the palm of a sterilely gloved hand for use. Pour the liquid into the cap of the bottle and dip the gauze as needed. Pour the liquid into a sterile container within the sterile field.

Pour the liquid into a sterile container within the sterile field

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

Replace the current gloves with a new set of sterile gloves.

The nurse is observing a sterile field that was prepared by another staff member. Which, if present, would indicate that the sterile field is contaminated? Sterile 4 × 4 gauze dressings, removed from the packaging and placed in the middle of the sterile field Sterile drape hanging off the work surface Sterile gloves, removed from the outer wrapping, 4 inches away from the edge of the sterile field Sterile drape positioned with the moisture-proof side facing up

Sterile drape positioned with the moisture-proof side facing up

The nurse is observing a sterile field that was prepared by another staff member. Which, if present, would indicate that the sterile field is contaminated? Sterile 4 × 4 gauze dressings, removed from the packaging and placed in the middle of the sterile field Sterile drape hanging off the work surface Sterile gloves, removed from the outer wrapping, 4 inches away from the edge of the sterile field Sterile drape positioned with the moisture-proof side facing up

Sterile drape positioned with the moisture-proof side facing up

When opening a pre-packaged kit to prepare a sterile field, which would be important to keep in mind? The outer 2-in (5-cm) border of the wrapper is considered contaminated. The edges of the wrapper are positioned to hang below the edges of the work surface. The inner surface of the outer wrapper is considered sterile. The outside surface of the outer wrapper becomes the sterile field.

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 occurrence would indicate that the nurse had contaminated the sterile drape? The nurse places the shiny side of the drape facing down. The nurse allows the drape to unfold gently. The nurse touches the sterile drape by its corners. The nurse allows the drape to touch his or her body.

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

The nurse assists a new nurse to add items to a sterile field. Which action by the new nurse requires further instruction? The nurse drops the item from the wrapper into the side of the sterile field. The nurse keeps hands and wrists on the outside of the wrapped sterile item. The nurse holds wrapped item in dominant hand to open, opening top flap away from body. The nurse grasps the remaining flap of the wrapper and pulls back toward wrist.

The nurse drops the item from the wrapper into the side of the sterile field

The nurse is performing a sterile dressing change. What action would require the nurse to put on a new pair of gloves? The nurse touches one glove to the other glove. The nurse picks up a sterile dressing from the sterile field. The nurse touches the client's skin with one hand. The nurse keeps both hands above waist level.

The nurse touches the client's skin with one hand. The nurse would need to put on a new pair of gloves if the ones being worn became contaminated, such as by touching the client's skin with one of the gloves. Picking up a sterile dressing from the field, keeping both hands above waist level, or touching one glove to the other glove would not cause contamination and thus not necessitate putting on a new pair of gloves.

The nurse is preparing to put on sterile gloves. When putting on the first glove, how does the nurse grasp the folded cuff? aka with what part of the hand?

Thumb and forefinger** When putting on sterile gloves, the nurse grasps the folded cuff of the first glove with the thumb and forefinger of the opposite hand. The other grasping positions are awkward and not attempted.

The nurse gathers supplies, including an extra pair of sterile gloves, for a sterile dressing change on a client's large abdominal wound. The nurse uses the extra gloves for what purpose? To be able to change gloves if the wound has copious draining To leave in the room with additional supplies for the next change To use if the first pair of sterile gloves gets contaminated To remove the existing dressing from the abdominal wound

To use if the first pair of sterile gloves gets contaminated Rationale: The nurse brings in extra sterile gloves in case the first pair is contaminated by touching a non-sterile surface. It is always better to plan that this might occur. The existing dressing is removed with clean gloves and is considered dirty. Any drainage should be on the dressing when it is removed. Handled according to the nurse's discretion but drainage does not usually indicate the nurse needs to change gloves. The gloves can be left for the next dressing change, but this is not the purpose of bringing them into the room.

When setting up a sterile field, the nurse opens a sterile package prepared by the facility. Which action would the nurse take first? Hold the package in the non-dominant hand. Pull the corners of the wrapper back toward the wrist. Reach over the package to open the side flaps. Unfold the top flap away from the body.

Unfold the top flap away from the body.

A nurse is preparing a sterile field using a pre-packaged kit. The nurse opens the outside cover and removes the kit, placing it in the center of the work surface. The nurse places the kit so that the topmost flap is positioned in which direction?

b. On the far side of the package After the nurse opens the outside cover of the package and removes the kit, the nurse places it in the center of the work surface with the topmost flap positioned on the far side of the package. Doing so allows sufficient room for the sterile field. Then the nurse would reach around the package and grasp the outer surface of the end of the topmost flap, holding no more than 1 in (2.5 cm) from the border of the flap. This flap is then pulled open away from the body.

The nurse is preparing a sterile field using a pre-packaged kit. After performing hand hygiene, which action would the nurse take next? Place the work surface at waist height Confirm the client's identity Remove the outer wrapper from the kit Place the package in the center of the work surface

confirm client's identity

The nurse has prepared a sterile field using a pre-packaged kit. Which would be important for the nurse to keep in mind? The items contained in the kit are considered clean. The field is contaminated if it is out of the nurse's site. No other sterile items can be added to the sterile field at this point. Sterile gloves are not needed to obtain any items from the field.

contaminated if out of the nurse's site

The nurse prepares for a sterile procedure. What action does the nurse perform first?

hand hygiene

The nurse is planning to use a pre-packaged kit to prepare a sterile field. Which would be of least importance in ensuring the sterility of the kit? The kit is dry. The kit is unopened. The outer wrapper is disposed in an appropriate receptacle. The expiration date is not yet reached.

outer wrapper is disposed in an appropriate receptacle