skills TEST 2 (2023)
The nurse is preparing to apply an external heating pad. To be effective yet not cause damage to the underlying tissue, what temperature range will the nurse set the pad? -90°F to 99°F (32.2°C to 37.2°C) -100°F to 104°F (37.7°C to 40°C) -105°F to 109°F (40.5°C to 43°C) -110°F to 115°F (43.3°C to 46.1°C)
105°F to 109°F (40.5°C to 43°C)
A nurse gives a 13-year-old client an ice bag to place over a sprained ankle. How long does the nurse have the client apply the bag before the nurse removes it? -10 minutes -15 minutes -20 minutes -25 minutes
20 minutes
When adding sterile items to a sterile field, the nurse would drop the sterile items from which height? -2 in (5 cm) -6 in (15 cm) -10 in (25 cm) -14 in (35 cm)
6 in (15 cm)
The nurse has removed the sutures and is now planning to apply wound closure strips. What does the nurse do before applying the strips? -Apply a skin protectant to the skin around the incision. -Apply a skin protectant to the incision site. -Apply a sterile gauze sponge over the incision site. -Apply a transparent dressing over the incision site.
Apply a skin protectant to the skin around the incision.
What action by the nurse is appropriate when attempting to remove surgical staples that have dried blood or drainage on them? -Go ahead and remove the staples; they will pop up and out of the skin. -Notify the health care provider of the dried blood and wait for a prescription to proceed. -Apply a warm compress to the surgical staples and allow the dried blood to melt. -Apply moist saline compresses to loosen crusts before attempting to remove the staples.
Apply moist saline compresses to loosen crusts before attempting to remove the staples.
When removing the old dressing from the site of a Penrose drain, the nurse notes that some of the dressing material has stuck to the client's skin. What action will the nurse take next? -Apply sterile saline to loosen the dressing material from the skin. -Gently pull the dressing material off the client's skin and observe for irritation. -Use an alcohol-based adhesive remover to aid in removal of the dressing. -Administer an analgesic to the client and warn the client this may be a little painful.
Apply sterile saline to loosen the dressing material from the skin.
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 recommended nursing intervention will the nurse take first in this situation? -Assess for pain, shortness of breath, and abdominal pressure. -Place the client in a sitting position to reduce pressure on the abdomen. -Leave the wound open and notify the health care provider. -Tell the client that this is a life-threatening situation and that the health care provider will be called.
Assess for pain, shortness of breath, and abdominal pressure.
When preparing a sterile field, which action is appropriate for the nurse to take first? -Place the work surface at chest height. -Open any sterile items to be used. -Check the packages for expiration date. -Put on sterile gloves.
Check the packages for expiration date.
The nurse is obtaining a wound culture and has removed the old dressing and discarded it, performed hand hygiene and applied fresh gloves. What will the nurse do next? -Cleanse the wound with a nonantimicrobial cleanser. -Assess the drainage for amount, type, color, and odor. -Dry the wound bed using a sterile sponge. -Open the culture tube and apply the swab to the wound bed.
Cleanse the wound with a nonantimicrobial cleanser.
After performing hand hygiene to prepare a sterile field using a prepackaged kit, which action will the nurse take next? -Remove the outer wrapper from the kit. -Place the work surface at waist height. -Place the package in the center of the work surface. -Confirm the client's identity.
Confirm the client's identity.
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 appropriate? -Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole. -Leave both the thumb and finger in the thumb hole and perform the procedure to the best of the nurse's ability. -Don a second pair of sterile gloves over the first pair. -Use only the correctly gloved hand to perform the sterile procedure while making sure the other hand does not contaminate the sterile field.
Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole.
When irrigating a client's wound, the nurse pours irrigation solution from the bottle into a sterile container. What is a recommended action for this step in the procedure? -Shake the bottle of irrigating solution before pouring. -Pour the chilled irrigating solution into the irrigation container. -Discard any irrigation solution remaining in the bottle. -Date and reuse leftover irrigation solution within 24 hours.
Date and reuse leftover irrigation solution within 24 hours.
The nurse is performing frequent skin assessment at the site where cold therapy has been in place. The nurse notes pallor at the site, and the client reports 'it feels numb.' What action does the nurse take at this time? -Discontinue the therapy and assess the client. -Notify the health care provider of the findings. -Document the findings in the client's medical record. -Gently rub and massage the area to warm it up.
Discontinue the therapy and assess the client.
The nurse is preparing to remove surgical staples. What will the nurse do with the surgical staples as they are removed from a surgical incision? -Dispose of them in a sharps container. -Dispose of them in a biohazard bag. -Save them for the health care provider to observe on rounds. -Wrap them up in a gauze sponge for disposal.
Dispose of them in a sharps container.
The nurse is caring for a client who has a Penrose drain. On assessment, the nurse notes that there is a safety pin on the drain just outside the wound incision area. What action will the nurse take related to this finding? -Document the presence and location of the safety pin. -Notify the health care provider of the finding at the incision site. -Obtain a wound culture to test for possible infection. -Remove the safety pin and clean with an antiseptic preparation.
Document the presence and location of the safety pin.
The nurse needs to place gauze from a wrapped item into the sterile field. Which action does the nurse take? -Drop the item from 6 in (15 cm) above the sterile field. -Lay the item in an open package on the 1-in (2.5-cm) border. -Remove the gauze from the package with one sterile hand. -Extend the sterile field by laying the open package beside it.
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. -Use hand sanitizer on the surface of the gloves prior to glove removal. -Wrap the discarded gloves inside the sterile field for waste disposal.
Ensure the skin of the hands does not touch the outside surface of the glove.
After 20 minutes, the nurse is preparing to remove the cold therapy application when the client asks if it can be left on a little longer. What action does the nurse take? -Leave the therapy on for 10 more minutes and return to remove it after that time. -Assist the client to get out of bed and sit up in a chair for a short while. -Explain that leaving cold therapy on for longer than 20 minutes can cause tissue necrosis. -Explain to the client that this is not possible because of the health care provider's prescription.
Explain that leaving cold therapy on for longer than 20 minutes can cause tissue necrosis.
After emptying the drainage from a Jackson-Pratt drain, which action will the nurse prioritize to re-establish suction to the drain? -Fully compress the bulb and reapply the cap. -Reapply the cap and fully compress the bulb. -Turn the suction back on at the wall unit. -This type of drain does not use suction.
Fully compress the bulb and reapply the cap.
When removing soiled gloves, which will the nurse do first? -Grasp the outside of one glove with the opposite gloved hand. -Turn the glove inside out as it is being pulled off. -Slide the fingers under the glove at the wrist. -Peel the glove off over the other glove
Grasp the outside of one glove with the opposite gloved hand.
Which statement 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. -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 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.
If the first pair is contaminated and needs to be replaced, the nurse does not need to leave the room for a new pair.
What action does the nurse perform to remove gloves after performing a sterile procedure? -Pull the glove off starting at the fingers. -Lay the first removed glove in the sterile field. -Invert the glove as it is removed. -Place the first removed glove in the waste.
Invert the glove as it is removed.
The nurse is teaching a client the purpose of using an external heating pad. What does the nurse include in the teaching plan? Select all that apply. -It reduces the discomfort of muscle tension and muscle spasms. -It helps to relieve pain from arthritis and joint stiffness. -It can be used to treat inflammation, chronic pain, and surgical wounds. -It promotes healing by decreasing perfusion to the site and decreasing edema. -It promotes healing by accelerating the body's natural inflammatory response.
It promotes healing by accelerating the body's natural inflammatory response. It reduces the discomfort of muscle tension and muscle spasms. It helps to relieve pain from arthritis and joint stiffness. It can be used to treat inflammation, chronic pain, and surgical wounds.
When applying an external heating pad, which prescription from the health care provider will the nurse question? -Leave heating pad on for 40 to 45 minutes, then off for 2 hours. -Assess site frequently during application of the heating pad. -Use gauze to secure the heating pad to the site of application. -Maintain the temperature between 105°F and 109°F (40.5°C and 43°C).
Leave heating pad on for 40 to 45 minutes, then off for 2 hours.
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. -Instill 50 ml of normal saline into the wound and loosely cover with packing material. -Insert rolled gauze into the wound; saturate it with povidone-iodine solution and cover with a moisture-impervious dressing. -Fill the wound with sterile saline gel and cover with a large transparent dressing.
Loosely pack the dampened dressing material to prevent too much pressure on the wound bed.
When assessing a wound 2 hours after removing the surgical staples, the nurse notes that the wound edges have begun to pull apart. What action does the nurse take? -Notify the health care provider that the wound edges are coming apart. -Apply a wet-to-dry saline dressing to the wound area. -Re-staple the surgical incision. -Call a rapid response.
Notify the health care provider that the wound edges are coming apart.
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? -Continue with the dressing change. -Obtain a new pair of sterile gloves. -Use the ripped glove for nonsterile actions. -Place a new sterile glove over the ripped glove.
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. -Give ciprofloxacin 1gram IV every 12 hours. -Assist client up to chair three times daily. -Consult dietitian to assist client with meal choices.
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? -Slide the gloves out of the package. -Reach under the package folds to open. -Obtain a new pair of sterile gloves. -Open the top and bottom folds completely.
Open the top and bottom folds completely.
The nurse has finished cleaning a client's surgical wound. What is the nurse's next action in this procedure? -Pat the wound dry with a sterile gauze sponge. -Allow the wound to air dry for 2 minutes. -Measure the length, depth, and width of the wound. -Position the client to promote drainage of the solution.
Pat the wound dry with a sterile gauze sponge.
The nurse has gathered several individually packaged dressings for a sterile dressing change. When adding these dressings to the sterile field, which action will the nurse take? -Tear open the package across the top. -Peel the edges apart with both hands. -Cut the package open with sterile scissors. -Pull the top cover off at an angle.
Peel the edges apart with both hands.
A nurse is assisting a surgeon who will be placing a hollow, open-ended rubber tube in an abscess to drain the wound. One end of the drain will be in the abscess and the other will pass through an opening in the skin known as a stab wound. Which type of drain will the nurse document the client will be receiving? -Penrose drain -T-tube drain -Jackson-Pratt drain -Hemovac drain
Penrose drain
The nurse prepares for a sterile procedure. What action does the nurse perform first? -Put on personal protective equipment, if required. -Perform hand hygiene. -Identify the client the procedure is prescribed for. -Place all the necessary supplies in the room.
Perform hand hygiene.
A nurse is collecting a wound culture from a client from two different sites. Which action(s) will 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. -Use the same swab for both wound sites. -Touch the swab to the intact skin at the wound edges. -Tap the outside of the culture tube with the swab before placing it in the tube.
Place a swab in the culture tube when done Insert swab into the wound Press and rotate the swab several times over the wound surfaces
The nurse is preparing to perform wound care. Which intervention will be prioritized to prevent injury to the nurse? -Raise the bed to elbow height. -Maintain a sterile field. -Position the client. -Gather all necessary equipment.
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. -Assure that the packing material is completely saturated when placed in the wound. -Use less packing material. -Discontinue application of saline-moistened packing and apply a hydrocolloid dressing instead.
Reduce the time interval between dressing changes.
The nurse assesses the surgical dressing of a client who has just arrived from the postanesthesia 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. -Change the dressing using sterile technique. -Notify the health care provider of the bleeding. -Call a rapid response and stay with the client.
Reinforce the dressing and assess site frequently.
What action will the nurse take to ensure a wound is ready for the sutures to be removed? -Remove every other suture and assess the wound edges. -Review the number of days the sutures have been in place. -Apply sterile saline to the suture site and assess the wound edges. -Apply gentle pressure to the incision and observe for dehiscence.
Remove every other suture and assess the wound edges.
The nurse is collecting a wound culture and has removed the current dressing and discarded it. What will the nurse do next? -Remove gloves and perform hand hygiene. -Twist and break the seal on the culture tube. -Assess and clean the wound per orders. -Identify the client using two client identifiers.
Remove gloves and perform hand hygiene.
While performing a sterile dressing change, the nurse inadvertently contaminates the right-hand glove. Which action by the nurse is appropriate? -Continue the procedure using only the left gloved hand. -Cover the contaminated glove with a nonsterile disposable glove. -Apply a new pair of sterile gloves over the current ones. -Replace the current gloves with a new set of sterile gloves.
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 is an appropriate action by the nurse? -Allow the wound to air dry. -Replace the dressing with a larger one. -Replace the dressing with a smaller one. -Notify the health care provider for further instructions.
Replace the dressing with a larger one.
What is the best way for the nurse to ensure there is not any tension on the tubing when caring for a client with a Jackson-Pratt drain? -Secure the drain to the client's gown with a safety pin below the level of the wound. -Tape the drain to the dressing material securely below the level of the wound. -Allowed the Jackson-Pratt drain to hang freely to avoid any kinks in the tubing. -Apply an abdominal binder over the entire wound and drain to support the site.
Secure the drain to the client's gown with a safety pin below the level of the wound.
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 their arm and touches the sterile field. Which action by the nurse is appropriate? -Add new sterile dressings to the sterile field. -Replace any items that moved with new ones. -Set up an entirely new sterile field. -Ask the client if they touched anything.
Set up an entirely new sterile field.
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? -Use the thumb and forefinger to grasp the cuff. -Hold the second glove in the palm of the gloved hand. -Slide the gloved fingers under the cuff of the second glove. -Use the fingers to grasp the edges of the cuff of the second glove.
Slide the gloved fingers under the cuff of the second glove.
Which action should be documented by the nurse? -Sterile technique was used for a given procedure. -The nurse donned gloves two different times during a procedure. -The nurse washed their hands before a procedure. -The specific items that were transferred into a sterile field.
Sterile technique was used for a given procedure.
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 will the nurse do first? -Notify the health care provider of the client's report of increased discomfort. -Document the event in the client's medical record. -Stop the heat application and completely remove the compress. -Administer the prescribed analgesic.
Stop the heat application and completely remove the compress.
Which is important for the nurse to keep in mind after preparing a sterile field using a prepackaged kit? -No other sterile items can be added to the sterile field at this point. -The items contained in the kit are considered clean. -The field is contaminated if it is out of the nurse's site. -Sterile gloves are not needed to obtain any items from the field.
The field is contaminated if it is out of the nurse's site.
The nurse is putting on sterile gloves. Which principleis important to keep in mind? -The hands should remain above waist level at all times. -The cuffs of the gloves should be adjusted as each glove is applied. -The inner package should be placed on the surface with the cuff side away from the body. -The outer edge of the cuff is used to pick up the glove to be put on.
The hands should remain above waist level at all times.
When opening a prepackaged kit to prepare a sterile field, which factor will the nurse keep in mind? -The outside surface of the outer wrapper becomes the sterile field. -The inner surface of the outer wrapper is considered sterile. -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 nurse is opening a package containing a sterile drape to establish a sterile field. Which occurrence indicates that the nurse had contaminated the sterile drape? -keeping the sterile field above waist level -The nurse allows the drape to touch their body. -Touching sterile field with sterile items - Never turning away from sterile field.
The nurse allows the drape to touch their body.
The nurse is irrigating a client's pressure injury. How does the nurse know when to stop irrigating the wound? -All the irrigation solution has been used. -The solution leaving the wound is a pink color. -The solution leaving the wound is a red color. -The solution leaving the wound is clear.
The solution leaving the wound is clear.
During sitz bath therapy, a client reports feeling dizzy and lightheaded. What is the likely rationale for this occasional effect from sitz bath therapy? -The cool water has caused the client to become cold. -The warm water caused vasodilatation. -The client's blood pressure has increased. -The client's wound has begun bleeding.
The warm water caused vasodilatation.
When setting up a sterile field, the nurse opens a sterile package prepared by the facility. Which action will the nurse take first? -Pull the corners of the wrapper back toward the wrist. -Hold the package in the nondominant hand. -Unfold the top flap away from the body. -Reach over the package to open the side flaps.
Unfold the top flap away from the body.
The nurse is caring for a client's wound that has a Jackson-Pratt drain in place. The nurse empties the chamber's contents into the graduated collection container What is the nurse's next step? -Fully compress the chamber. -Replace the cap on the chamber. -Use a gauze pad to clean the outlet. -Put on clean gloves.
Use a gauze pad to clean the outlet.
Which action by the nurse is appropriate when the sutures are difficult to remove because of crusted dried blood? -Use a sterile gauze and sterile saline to gently remove the crusted dried blood. -Cut the crusted dried blood off using sterile scissors and tweezers. -Notify the health care provider of the findings and that the sutures cannot be removed. -Use a sterile alcohol preparation to soak the sutures until they soften.
Use a sterile gauze and sterile saline to gently remove the crusted dried blood.
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. Which action does the nurse prioritize in this situation? -Wipe the area with an alcohol wipe and pull the dressing from the skin. -Wipe the area with an antimicrobial swab and pull the dressing from the skin. -Use small amounts of sterile saline to help loosen and remove the dressing. -Soak the area with sterile water using gauze pads.
Use small amounts of sterile saline to help loosen and remove the dressing.
When removing soiled gloves, which action will the nurse take? -Slide the fingers of the gloved nondominant hand between the skin and glove of the dominant hand. -Pull on the fingertips of the gloved nondominant hand using the fingers of the gloved dominant hand. -Grab the gloved dominant hand at the wrist using the fingers of the nondominant hand to invert the glove. -Using the gloved dominant hand, grasp the glove of the nondominant hand near the cuff on the outside.
Using the gloved dominant hand, grasp the glove of the nondominant hand near the cuff on the outside.
The nurse is preparing to clean a wound site with a Penrose drain. Which method will the nurse use? -a circular motion beginning at the pin site and moving outward toward the edge of the wound -a wedge pattern from pin site to outer edge of wound and repeat -an up-and-down pattern beginning on left side of pin and then to right side -a circular motion beginning at the outer edge of the wound and moving in toward the pin site
a circular motion beginning at the pin site and moving outward toward the edge of the wound
The nurse is caring for a client with a pressure injury on the heel of the foot. The injury is covered with stable black eschar. What is the best nursing intervention at this time? a. Teach the client ways to relieve the pressure on the heel. b. Prescribe the client a high carbohydrate diet to promote healing. c. Remove the eschar by irrigating with sterile saline. d. Teach the client to reposition every 4 hours.
a. Teach the client ways to relieve the pressure on the heel.
The nurse is teaching a client's caregiver about ways to help prevent skin breakdown. What action should the nurse teach as an important intervention to prevent pressure injury development? a. Turn and reposition the client every 2 hours. b. Keep the head of the bed elevated 35 degrees. c. Pull the client up in the bed very gently. d. Gently massage any reddened areas for several minutes.
a. Turn and reposition the client every 2 hours.
The nurse has documented that a client has an unstageable pressure injury. Which type of wound has the nurse discovered? a. black-brown eschar covering the top b. exposed bone, tendon, or muscle visible c. redness with partial-thickness loss of dermis d. bright red granulation tissue in the wound bed
a. black-brown eschar covering the top
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? a. deep tissue injury b. unstageable, skin intact c. stage 1 pressure injury d. stage 2 pressure injury
a. deep tissue injury
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? a. stage 1 pressure injury b. stage 2 pressure injury c. deep tissue injury d. unstageable, skin intact
a. stage 1 pressure injury
The nurse is preparing to remove sutures from a client's abdominal surgical site that was sutured 14 days ago and appears to be well healed. Which equipment will the nurse gather to complete this task? Select all that apply. -sterile gloves -face mask -adhesive wound closures strips -skin protective /barrier wipes -gauze
adhesive wound closures strips, D.skin protective /barrier wipes, gauze
The nurse is caring for a client with a Jackson-Pratt drain. Which intervention by the nurse is priority before beginning the dressing change? -assessing the need for analgesia -assessing the client's need to void -gathering the needed supplies -checking the client's latest laboratory values
assessing the need for analgesia
The nurse is caring for several clients on the unit. Which client has the highest risk of developing a pressure injury? a. 17-year-old client postoperative for fracture of the upper extremity b. 25-year-old client on bed rest for 24 hours following a procedure c. 47-year-old client with severe alcohol use disorder and a traumatic brain injury resulting in unconsciousness d. 84-year-old client diagnosed with a urinary tract infection who frequently gets out of bed without calling for assistance
c. 47-year-old client with severe alcohol use disorder and a traumatic brain injury resulting in unconsciousness
When applying a warm compress, which client will benefit most from the application of moist heat instead of dry heat? -client who needs relief from muscle tension and occasional spasms -client with chronic arthritic joint pain -client with a wound with inflammation -client who requires the heat to penetrate deeply into the tissues
client who requires the heat to penetrate deeply into the tissues
The nurse notes a health care provider has prescribed an external heating pad for several clients. For which client will the nurse question the health care provider before applying the pad? -client with bleeding wound -client with infected wound -client with chronic arthritic pain -client with muscle spasms from tension
client with bleeding wound
The nurse is preparing to clean a client's surgical wound. What will the nurse assess before beginning the procedure? -client's comfort and effectiveness of pain medication -color of drainage on the wound dressings -any physical limitations the client may have -client's temperature and pulses
client's comfort and effectiveness of pain medication
The nurse assists a new nurse to add items to a sterile field. Which action by the new nurse requires further instruction? -grasping the remaining flap of the wrapper and pulling back toward wrist -keeping hands and wrists on the outside of the wrapped sterile item -dropping the item from the wrapper into the side edges of the sterile field -holding wrapped item in dominant hand to open and opening top flap away from body
dropping the item from the wrapper into the side edges of the sterile field
Which factor(s) will the nurse verify when preparing to set up a prepackaged kit to ensure its sterility? Select all that apply. -expiration date -kit's dryness -whether the kit is unopened -outer wrapper's proper disposal -properly sterilized work surface properly before starting
expiration date, kit's dryness, whether the kit is unopened
The nurse is positioning a client with a pressure injury to prepare to irrigate the wound. How will the nurse direct the flow of irrigation solution over the wound? -from the lower end of the wound to the upper end -from the upper end of the wound to the lower end -from the left side of the wound to the right side -from the right side of the wound to the left side
from the upper end of the wound to the lower end
When evaluating the effectiveness of sitz bath therapy, what outcome will the nurse expect? -increased comfort of client -increased drainage from wound site -decreased need for dressing changes -decreased anxiety of client
increased comfort of client
The nurse uses a small amount of sterile solution from a large, multiuse bottle to moisten gauze in a sterile field. Where should the nurse pour the liquid? -onto gauze on the sterile field until the gauze is moist -into the cap of the bottle, dipping the gauze as needed -into a sterile container within the sterile field -into the palm of a sterilely gloved hand for use
into a sterile container within the sterile field
When irrigating an infected wound, which action by the nurse best helps to prevent contamination of the irrigation syringe? -keeping the tip of the syringe at least 1 in (2.5 cm) above the wound -directing the flow of irrigating solution from the top of the wound -positioning the client to face away from the sterile supplies -cleaning the tip of the syringe with an alcohol wipe after each use
keeping the tip of the syringe at least 1 in (2.5 cm) above the wound
The nurse opens the outside cover and removes a prepackaged 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? -to the right of the client -toward the nurse's body -on the far side of the package -to the left of the nurse
on the far side of the package
When putting on the second sterile glove, the nurse places the gloved thumb at which location? -close to the palm of the gloved hand -outward away from the gloved hand -adjacent to the fifth finger -under the fingers, as in a fist
outward away from the gloved hand
The nurse needs to place a dressing under and around a Penrose drain. Which dressing is best for the nurse to obtain? -precut 4 × 4 sterile drain sponge -sterile 2 × 2 gauze sponge -nonadherent petrolatum dressing gauze -roll of sterile prewoven gauze
precut 4 × 4 sterile drain sponge
The nursing instructor observes the nursing student removing sterile gloves. Which action indicates the need for further teaching? -using one gloved hand to grab the outside surface of the other glove -reaching under the glove on one hand to peel the glove off of the other hand -rolling gloves into each other during removal for disposal in the waste can -pulling the gloves off starting with the fingertips prior to removal
pulling the gloves off starting with the fingertips prior to removal
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? -pushing motion -rotating motion -back-and-forth motion -up-and-down motion
rotating motion
To assess for circulatory compromise, what assessment(s) will the nurse perform at the site of application before applying a warm compress? Select all that apply. -skin color -distal pulses -evidence of edema -presence of sensation -respiratory rate
skin color distal pulses evidence of edema presence of sensation
The nurse is irrigating a client's wound using sterile technique. When directing the irrigating solution into the wound, what does the nurse use to collect the solution? -used wound dressing -waterproof pad -sterile basin -gauze
sterile basin
The nurse is preparing to put on sterile gloves. When putting on the first glove, how does the nurse grasp the folded cuff? -index and second finger -thumb and forefinger -second, third, and fourth fingers -thumb and fifth finger
thumb and forefinger
What intervention will the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples? -to splint the area when engaging in activity -to ambulate using a cane or walker -to remain in bed for the next 4 hours -to turn the head away from the area whenever they cough
to splint the area when engaging in activity
After setting up a sterile field and putting on sterile gloves, the nurse prepares to clean a client's surgical wound. Which cleaning technique does 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. -outside to center using a new gauze for each wipe. -side to side using a new gauze for each wipe. -distal to proximal using a new gauze for each wipe.
top to the bottom using a new gauze for each wipe.
The nurse is performing a sterile dressing change. What action would require the nurse to put on a new pair of gloves? -touching the client's skin with one hand -picking up a sterile dressing from the sterile field -keeping both hands above waist level -touching one glove to the other glove
touching the client's skin with one hand
Which assessment finding(s) will the nurse use to determine the stage of a client's pressure injury? Select all that apply. a. visibility of subcutaneous fat b. thickness of tissue loss c. visibility of bone, tendon, or muscle d. skin in area is red and warm to touch e. drainage that is foul smelling and green in color
visibility of subcutaneous fat, thickness of tissue loss, visibility of bone, tendon, or muscle
How often will the nurse empty a Jackson-Pratt drain? Select all that apply. -when the drain is one-half to two-thirds full -only when the drain is full -once every 12 hours -once every 24 hours
when the drain is one-half to two-thirds full
How will the nurse secure a Jackson-Pratt drain after emptying it? -with a safety pin, securing the drain to the client's gown below the wound -with a safety pin, securing the drain to the client's gown above the wound -with tape, securing the drain to the client's gown above the wound -with a safety pin, securing the drain to the side of the bedding.
with a safety pin, securing the drain to the client's gown below the wound
The nurse is observing a sterile field that was prepared by another staff member. Which, if present, indicates that the sterile field is contaminated? a. zterile drape positioned with the moisture-proof side facing up b. zterile drape hanging off the work surface c. zterile 4 × 4 gauze dressings, removed from the packaging and placed in the middle of the sterile field d. zterile gloves, removed from the outer wrapping, 4 inches away from the edge of the sterile field
zterile drape positioned with the moisture-proof side facing up
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. How will the nurse respond? -'I cannot do that because your health care provider only prescribed it for 30 minutes at a time.' -'Leaving it on for more than 30 minutes can cause complications such as tissue injury.' -'Ok, we can leave it on for about 10 more minutes then I will return to remove it.' -'Because it is making you feel better, I will call the health care provider and ask to leave it on longer.'
'Leaving it on for more than 30 minutes can cause complications such as tissue injury.'
