NUR 311

The 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?"

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 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."

After 30 minutes, the nurse comes to remove the warm compress from a client's wound site. The client requests to leave the warm compress on a little longer. What is the best response by the nurse?

"Leaving it on for more than 30 minutes can cause complications such as tissue injury."

Place in order, from first to last, the actions the nurse will perform when applying a warmed moist compress. Use all options

1)Assess the application site. 2)Remove the compress from the warmed solution. 3)Squeeze out any excess solution. 4)Gently mold the compress to the intended site. 5)Cover the site with a dry, clean bath towel.

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 capping an intravenous (IV) line for intermittent use. Place in order how the nurse will perform these actions. Use all options.

1)Scrub the needleless connector or end cap on the extension tubing with an antimicrobial swab. 2)Insert the saline flush syringe into the needleless connector or end cap on the extension tubing 3)Aspirate the catheter for positive blood return by gently pulling back on the syringe. 4)Flush the tubing slowly, over one minute, with a sterile saline filled syringe. 5)Reclamp the extension tubing and loop it near the entry site, securing it with tape.

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.

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 seconds

A nurse would perform additional monitoring of the IV site and infusion according to facility policy for which client?

A client who is receiving IV medications.

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

Adult client who is comatose

Which client would be at highest risk for experiencing fluid overload as a complication of IV therapy?

An older adult client receiving an IV infusion for pneumonia.

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 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?

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

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

Before entering a client's room, After removing gloves, After applying a clean & dry dressing

The nurse knows that monitoring the infusion rate and IV site is a nursing responsibility. When does the nurse routinely monitor client IVs?

Beginning of the work shift.

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.

A client has a peripheral access IV infusion running via an electronic infusion device. While monitoring the infusion, the nurse notices that the electronic infusion device is not running. What should the nurse do?

Check the electronic device for proper functioning.

The nurse is monitoring an IV site for a client who reports that the needle feels "funny." What should the nurse do first?

Check the integrity of the IV system, IV solution and tubing, and flow rate.

The nurse is collecting a wound culture from a client's puncture wound. What is the nurse's first step in the procedure?

Clean the wound.

What action should the nurse take when changing a sterile dressing on a central venous access device?

Cleanse the central venous access device site while wearing sterile gloves

The nurse is obtaining a wound culture and has removed the old dressing and discarded it, performed hand hygiene and applied fresh gloves. What should the nurse do next?

Cleanse the wound with a non antimicrobial cleanser.

Which hospitalized clients are good candidates for capping of an existing intravenous line for intermittent use? Select all that apply.

Client who is only receiving fluids at a keep-vein-open rate., Client who needs infusions of an antibiotic only every 12 hours., Client who no longer requires intravenous infusions.

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

Client's medical record

The nurse is capping a client's IV line for intermittent use in preparation for the administration of an antibiotic. After inspecting the site, what will the nurse do next?

Close the clamp on the current administration set.

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.

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?

Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole.

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?

Deep tissue injury

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.

The nurse is assessing a client's peripheral venous access site and notes redness and inflammation at the site. What is the best action by the nurse at this time?

Discontinue current IV and relocate to new site.

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?

Dry the hands with a paper towel.

While removing gloves after performing client care, what action does the nurse take?

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

A nurse is changing a client's peripheral venous access dressing. The nurse finds that the site is bleeding and oozing. Which type of dressing should the nurse use for this client?

Gauze dressing

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

Gloves

When removing soiled gloves, which should the nurse do first?

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

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

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

A nurse is collecting a wound culture from a client from two different sites. Which actions should the nurse take while performing this procedure? Select all that apply.

Insert a swab into the wound. Press and rotate the swab several times over the wound surfaces., Place the swab in the culture tube when done.

What action does the nurse perform to remove gloves after performing a sterile procedure?

Invert the glove as it is removed.

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

Keep the hands below the elbows.

The nurse has just successfully inserted an intravenous (IV) catheter and initiated IV fluids. Which items should the nurse document? Select all that apply.

Location of the IV catheter access, Type of IV solution, Gauge and length of the IV catheter, Client's reaction to the procedure, Rate of the IV solution

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?

Loosely pack the dampened dressing material to prevent too much pressure on the wound bed.

Inspection of a client's peripheral venous access site reveals signs of phlebitis. Which action by the nurse would be most appropriate?

Notify the health care provider, discontinue the IV, and start it at another site.

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?

Obtain a new pair of sterile gloves.

The nurse is caring for a client with an abdominal wound and prescriptions from the health care provider. Which prescription will the nurse initiate first?

Obtain a sterile wound culture

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?

Open the top and bottom folds completely.

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

Outward away from the gloved hand

While assessing the IV site of a client who has had abdominal surgery, the nurse suspects infiltration. Which finding would help support the nurse's suspicions?

Pallor

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

Pat the wound dry with a sterile gauze sponge.

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.

When monitoring the peripheral access IV sites of various clients receiving IV therapy, the nurse would assess closely for which finding as the most common complication related to IV therapy?

Phlebitis Rationale:The most common complication related to IV therapy is phlebitis. Chemical irritation or mechanical trauma can cause injury to the vein and lead to phlebitis

To assess for circulatory compromise, what assessments will the nurse perform at the site of application before applying a warm compress? Select all that apply.

Presence of sensation, Skin color, Distal pulses, Evidence of edema

The nurse changes a client's peripheral venous access dressing. Which nursing action is correct?

Press the chlorhexidine applicator against the skin using a back-and-forth motion.

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

Raise the bed to elbow height.

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?

Reduce the time interval between dressing changes.

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 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?

Reinforce the dressing and assess site frequently Rationale: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.

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.

The nurse is collecting a wound culture and has removed the current dressing and discarded it. What should the nurse do next?

Remove gloves and perform hand hygiene.

The nurse is responding to a client's call light. The client states, "I was getting out of bed and caught my IV on the side rail. I think I may have pulled it out." The nurse determines that the intravenous (IV) catheter has been almost completely pulled out of the insertion site. Which action is most appropriate?

Remove the IV catheter and reinsert another in a different location.

The nurse has just flushed a peripheral venous access site and notices fluid leaking from the insertion site. Which action is most appropriate?

Remove the IV catheter and restart the venous access site in a new location

The nurse is monitoring a client receiving an IV infusion to replace fluids lost during surgery and notices air bubbles in the tubing above the roller clamp. Which action would be most appropriate?

Remove the bubbles by closing the roller clamp, stretching the tubing downward and tapping the tubing with a finger.

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 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?

Replace the dressing with a larger one.

When collecting a culture from a client's wound, according to evidence-based practice, which type of motion will the nurse use when applying the swab to the wound tissue to obtain the most accurate results?

Rolling motion

While assessing a client receiving peripheral IV therapy as part of the treatment plan for hypovolemia, the nurse suspects that the client is experiencing fluid overload based on which finding?

Shortness of breath.

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?

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

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?

Stage 1 pressure injury

When assessing the area of application of a warm compress, the nurse observes skin maceration of the surrounding area, and the client reports increased discomfort. What should the nurse do first?

Stop the heat application and completely remove the compress.

A nurse is assessing a client's intravenous (IV) site while changing the dressing. Which signs would indicate fluid infiltration into the tissue around the IV catheter? Select all that apply.

Swelling, Pallor, Coolness

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.

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

The client's comfort and effectiveness of pain medication

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 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 is performing a sterile dressing change. What action would require the nurse to put on a new pair of gloves?

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

Which situation would warrant the need for the nurse to change a client's venous access dressing?

The skin around the site is wet.

The nursing instructor observes the nursing student removing sterile gloves. Which action indicates the need for further teaching?

The student pulls the gloves off starting with the fingertips prior to removal.

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

The students wash their hands for 15 seconds prior to drying them.

The nurse is preparing to put on sterile gloves. When putting on the first glove, how does the nurse grasp the folded cuff?

Thumb and forefinger

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

To prevent infection transmission

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

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 use if the first pair of sterile gloves gets contaminated

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 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?

Turn and reposition the client every 2 hours.

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?

Unfasten the gown at the waist.

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

Unfasten the ties at the neck and back.

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?

Use Montgomery straps instead of adhesive tape to hold the dressing in place. 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).

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?

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

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

Using a rubbing, circular motion

When removing soiled gloves, which action should the nurse take?

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

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, who is monitoring the IV site of a client receiving peripheral venous fluid therapy, checks for bleeding at the site. The nurse understands that bleeding at an IV site is most likely to occur at which time?

When the IV is discontinued.

The nurse is caring for a client who has been diaphoretic and observes that the dressing on the peripheral venous access site has become loose and needs changing. Which type of dressing would be best for this client?

a sterile gauze dressing

The nurse is capping an existing IV line for intermittent use. Which action by the nurse follows correct procedure?

cleaning the end cap of the extension tubing with an antimicrobial swab

The 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

gown

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

has black brown eschar covering the top. Rationale: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.

Which action by the nurse is most important to ensure the client's safety when changing a peripheral venous access device dressing?

placing the bed in the lowest position before leaving the room

When applying a warm compress, which client will benefit most from the application of moist heat instead of dry heat? A client who

requires that the heat penetrate deeply into the tissues.

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:

top to the bottom using a new gauze for each wipe.