PrepU Safe Practice I

Which of the following statements best explains the rationale for bringing an extra pair of sterile gloves into an adult patient'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. E: If the first pair is contaminated and needs to be replaced, the nurse does not need to leave the room for a new pair.

Which nursing action is a component of medical asepsis?

Handwashing after removing gloves E: 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).

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?

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. E: Holding 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 is the correct step for adding a sterile solution. The tip of the solutions should never touch the container or dressing, and the label should face the palm when pouring the solution. Only a used bottle of solution needs to be lipped. The bottle should be held outside the edge of the sterile field.

A nurse is caring for a client who is disoriented to time, place, and person and is attempting to get out of bed and pull out an intravenous line. The nurse receives orders from a health care provider to apply a vest restraint and bilateral soft wrist restraints. In carrying out this order, which nursing actions would be appropriate? Select all that apply. Perform a face-to-face behavior evaluation every hour. Tie the restraints in quick-release knots. Tie the restraints to the side rails of the bed. Document the client's condition. Document alternative methods used before the restraints were applied. Document the client's response to the intervention.

Perform a face-to-face behavior evaluation every hour. Tie the restraints in quick-release knots. Document the client's condition. Document alternative methods used before the restraints were applied. Document the client's response to the intervention. E: Preventing a client from a fall or harm is of utmost importance. Applying restraints is a last resort when all other alternative interventions have been attempted. A face-to-face evaluation must be performed every hour. Restraints are tied in knots that can be released quickly and easily. The nurse would document the client's condition, any alternative methods used before the restraints were applied, and the client's response to the interventions. Restraints would never be secured to side rails because doing so can cause injury if the side rail is lowered without untying the restraint.

The nurse is caring for a client with Clostridium difficile infection. Upon entering the room, which of the following steps should the nurse take?

Put on an isolation gown and gloves. E: Contact precautions should be implemented when a client has, or is suspected of having, an organism that can be transmitted by direct contact. This can occur when a nurse provides direct care or indirect contact where the organism is transferred to an object and then touched by a person. Contact precautions require that the nurse wear an isolation gown and gloves when entering the room.

A staff development nurse is discussing techniques to prevent back injury with a group of nursing assistants. The nurse informs the group that back stress and injury can be prevented by doing which of the following?

Spreading feet shoulder-width apart to broaden the base of support E: Techniques that prevent back stress and injury include spreading the feet shoulder-width apart to broaden the base of support; pushing equipment, rather than pulling, whenever possible; holding the object you are lifting or moving close to the body; and using the longest and strongest muscles of the arms and legs to provide power needed in strenuous activities because the muscles of the back are less strong and more easily injured.

A nurse is performing a venipuncture on a patient and notices that there is a hole in one of the sterile gloves. What would be the appropriate action to take to maintain a sterile field?

Stop the procedure, remove damaged gloves, perform handwashing, and open new sterile gloves. E: If a hole or tear is noticed in one of the gloves during the procedure, you should stop the procedure, remove damaged gloves, wash hands or perform hand hygiene (depending on whether soiled or not), and put on new sterile gloves.

The nurse planning to insert an indwelling urinary catheter into a client should utilize which of the following techniques?

Surgical asepsis E: Surgical asepsis, also known as sterile technique, is utilized to keep objects and areas free from microorganisms when performing surgery and procedures such as inserting an indwelling urinary catheter or IV catheter. Medical asepsis reduces the number and transfer of pathogens. Universal precautions and contact precautions help to decrease the risk of transmitting infection.

A client newly diagnosed with tuberculosis (TB) is being admitted with a prescription for "isolation precautions for tuberculosis." The nurse should assign the client to which type of room?

a private room to implement airborne precautions E: Isolation precautions for possible TB include implementing airborne precautions. The client should be placed in a private room and healthcare workers should wear a fit -tested N95 or higher level respirator to prevent transmission. Droplet precautions would be needed to prevent the transmission of illness spread by coughing or sneezing and require the donning of a surgical mask. Standard precautions are used with all clients. Contact precautions are required to prevent the transmission of illness spread through contact. Precautions include gown and gloves.

The nurse is caring for a client who is in contact isolation for an infection. The client informs the nurse that a shaman will be coming to visit and asks for privacy during that time. The most appropriate response from the nurse will be which of the following?

"When the shaman arrives I will help him with the personal protective equipment he will need." E: Nurses should make an effort to accommodate the client's beliefs while also advocating for the treatment proposed by health science.

You are caring for a patient who has an infection spread by respiratory droplets and is in Droplet Precautions. The patient asks, "Can my spouse visit me?" Which of the following responses is correct?

"Yes, as long as your spouse wears a mask and stays at least 3 feet away from you." E: PPE should be worn when entering the room for all interactions that may involve contact with the patient and potentially contaminated areas in the patient's environment. Keep visitors 3 feet from the infected person.

A client is admitted on the day of surgery for an arthroscopy of the left knee. Which nursing activities should be completed prior to administering anesthesia to the client to avoid wrong-site surgery? Select all that apply. - Verify that the surgeon has marked with a permanent marker the correct knee for the surgical site. -Verbally ask the client to state his or her name, surgical site, and procedure. -Verify the correct client with the correct operative site from medical records and diagnostic reports. -Call a "time-out" in the operating room to have the surgeon verify the correct knee before making the incision. -Show the client an anatomic model of the surgery site.

A,B,C,D Explanation : The root cause of wrong-site surgery involves a breakdown in communication between the client and family and the health care team. Information retrieved from the client in the preoperative assessment, such as the client's name, surgical site, and procedure, should be verbally assessed and verified with medical records and radiographic diagnostic reports. This information should be compiled in a checklist that the intraoperative team can recheck, thus avoiding unnecessary distraction and delay in the operating room. The nurse in the operating room is responsible for calling a "time out" so that every surgical team member can double-check the correct site of surgery, verify the site using the operative consent form, and verify that the surgeon has marked the operative site on the client. Showing the client an anatomic model will assist the client in understanding the location of the surgery, but it will not prevent anyone from identifying the wrong site on the client.

Many orthopedic-related injuries occur while participating in sports or in the workplace. Elements of client and family teaching aiming at prevention include which of the following? A. All options are correct. B. Use proper equipment at work and during participation in athletic activities. C. At work, look at ways to modify the environment to prevent injury. D. Exercise regularly to maintain joint and muscle strength.

A. E : Use proper equipment at work and during participation in athletic activities. At work, look at ways to modify the environment to prevent injury. Exercise regularly to maintain joint and muscle strength.

Surgical asepsis is defined as A. Absence of all virulent microorganisms B. Absence of all microorganisms C. Slowed growth of microorganisms D. Use of handwashing, gowning, and gloving

A. E: Surgical asepsis refers to sterile technique and indicates procedures used to eliminate any microorganisms.

After an infant undergoes surgical repair of a cleft lip, the physician orders elbow restraints. For this infant, the postoperative care plan should include which nursing action? A.removing the restraints every 2 hours B. removing the restraints while the infant is asleep C. keeping the restraints on both arms only while the child is awake D. using the restraints until the infant recovers fully from anesthesia

A. Explanation : Removing one elbow restraint at a time every 2 hours for about 5 minutes allows exercise of the arms and inspection for skin irritation. To prevent the infant from touching and disrupting the suture line, the nurse should use the restraints when the infant is asleep and awake. The nurse should maintain the elbow restraints from the time the infant recovers from anesthesia until the suture line is healed.

The primary reason for lubricating the urinary catheter generously before inserting the catheter into a male client is to prevent which problem? A. spasms at the orifice of the bladder.. B. friction along the urethra when the catheter is being inserted.. C. the number of organisms gaining entrance to the bladder.. D. the formation of encrustations that may occur at the end of the catheter

B. Explanation : Liberal lubrication of the catheter before catheterization of a male reduces friction along the urethra and irritation and trauma to urethral tissues. Because the male urethra is tortuous, a liberal amount of lubrication is advised to ease catheter passage. The female urethra is not tortuous, and, although the catheter should be lubricated before insertion, less lubricant is necessary. Lubrication of the catheter will not decrease spasms. The nurse should use sterile technique to prevent introducing organisms. Crusts will not form immediately. Irrigating the catheter as needed will prevent clot and crust formation.

Mental health laws in each state specify when restraints may be used and which type of restraints may be used. Most laws stipulate that restraints may be used: A. for a maximum of 2 hours. B. as necessary to control the client. C. if a client poses a present danger to himself or others. D. only with the client's consent.

C. Explanation : Most states / provinces / territories allow restraints to be used if the client presents a danger to himself or to others and if all other less-restrictive measures haven't worked. The client's danger level must be reevaluated every few hours. If the client is still a danger, restraints may be used until the violent behavior abates. No standing orders for restraints are allowed, and restraints are permitted only until less-restrictive measures, such as sedatives, become effective. Violent clients who are intoxicated with drugs or alcohol present a problem because they can rarely be sedated until the drug or alcohol is metabolized. In such cases, restraints may be needed for a longer period, but the client must be closely observed. Obtaining consent isn't always possible, especially when the client's violent behavior results from a psychosis such as schizophrenia.

A nurse is administering an anti-hypertensive drug to a hospitalized patient. What action should the nurse take to identify the patient prior to administration?

Check the patient's ID bracelet. E: Checking the patient's ID bracelet is one of the two suggested patient identifiers. Calling the patient by name is inappropriate because the patient may answer "yes" to the name being called, especially if they are hard of hearing. Checking the patient's record would not help because the patient himself must be identified. Checking with the family or significant others is not one of the suggested identifiers.

You are reviewing a patient's newly written medication order and are unable to read the prescriber's handwriting. Which of the following actions by is most appropriate?

Contact the prescriber to clarify the order. E: You must clarify the order with the person who wrote it.

A client is being sent home with oxygen therapy. The nurse instructs that A. Oxygen is addictive and its use must be decreased. B. The client will not be able to travel with oxygen. C. The client should raise the flow of oxygen if shortness of breath increases. D. Smoking or a flame is dangerous near oxygen.

D. Explanation : The nurse should cautions the client against smoking or using a flame near oxygen. Oxygen is not addictive. Clients can travel with portable oxygen systems. Teaching also includes the proper flow of oxygen.

The nurse understands that the purpose of the "time out" is to: A. verify all necessary supplies are available. B. identify the client's allergies. C. clarify the roles of the OR personnel. D. maintain the safety of the client.

D. E: Verification of the identification of the client, procedure, and operative site are essential to maintain the safety of the client.

A client with an infected abdominal wound must be placed on contact precautions for 10 days. What should the nurse do to help meet the client's emotional needs?

Describe why the client is on contact precautions and what will occur there, and reassure the client. E: To meet the client's need for information and help reduce the client's anxiety, the nurse should describe the reasons for contact precautions and how they are carried out and should also provide reassurance and empathy. To reduce the client's feelings of isolation, visitors should be allowed to spend time with the client or telephone. The client needn't limit movements while on contact precautions. Unnecessary personal items usually aren't permitted when a client is on contact isolation.

A student nurse is performing a urinary catheterization for the first time and inadvertently contaminates the catheter by touching the bed linens. What should the nurse do to maintain surgical asepsis for this procedure?

Gather new sterile supplies and start over. E: When following surgical asepsis, areas are considered contaminated if they are touched by any object that is not also sterile. One of the most important aspects of medical and surgical asepsis is that the effectiveness of both depends on faithful and conscientious practice by those carrying them out.

While observing a new nurse inserting an indwelling urinary catheter, the preceptor observes a break in sterile technique. What is the preceptor's best first action?

Tell the new nurse that a break in sterile technique has occurred and the procedure must be stopped. E: The most important priority is to ensure the client's safety. Since the new nurse has contaminated the sterile field, the risk of introducing infection is high. The procedure must be discontinued. Since the preceptor is working with the new nurse, it would not be necessary to report the new nurse's error to the nurse manager unless it became a pattern of behavior. Assigning the nurse to watch instructional videos might be appropriate, but after the client care issue is resolved.

A nurse preceptor is observing a new graduate during care of a client in contact isolation. Which action by the new graduate indicates a need for further teaching about handling infectious materials?

The nurse uses alcohol gel to clean her hands after changing linen soiled with urine and feces. E: Using alcohol gel isn't acceptable after the nurse has been in contact with soiled material. The nurse should wash her hands with soap and water. The nurse demonstrates appropriate handling of infectious materials by wearing gloves with each client contact, washing her hands with soap and water when she enters and exits the room, and disposing contaminated articles in the room's biohazard container.

The nurse in the pediatric unit is caring for a 10-year-old boy admitted with dehydration and diarrhea after eating chicken contaminated with Salmonella bacteria. What action taken by the nurse would be the most effective in preventing the spread of the infectious microorganism?

Washing hands before and after providing the client care E: Hand washing and sterile techniques are two significant measures to prevent the occurrence and transmission of infection in health care settings. Salmonella is spread through contaminated food and feces. There is no need to wear gloves to take the client's blood pressure and pulse. All soiled clothing should be placed in a sealed plastic bag before being sent home. The client ate contaminated chicken before he arrived at the hospital. There is no indication that the hospital food is contaminated.

A patient is placed in isolation for suspected tuberculosis. Which of the following actions should the nurse take when entering the patient's room?

Wear an N-95 respirator E: Tuberculosis is acquired via airborne transmission. With airborne precautions, the room door must remain shut to ensure the effectiveness of the negative pressure room. All personnel entering the room should wear an N-95 respirator or similarly approved respirator. A simple face mask with an eye shield is not an effective barrier to stop transmission. There is no need to minimize verbal interactions with a patient with tuberculosis.