311L module 2 (CP quizzes & rationales)

Which question by the nurse, to the client, will best help evaluate the outcome of having applied cold therapy? A. "Do you feel your muscle spasms have decreased?" B. "Does your dressing feel like it is too tight?" C. "Can I help you get up to the chair now?" D. "Have you noticed any increase in the wound drainage?"

A. "Do you feel your muscle spasms have decreased?" The outcomes the nurse should expect from cold therapy include that the client experiences decreased pain/discomfort, there is decreased swelling and inflammation at the site, and the client experiences fewer muscle spasms. Therefore, the question which will best help evaluate the outcome of having applied cold therapy is asking the client if the muscles spasms have decreased. While they may be important, the other questions do not directly address the expected outcomes of cold therapy.

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? A. 15 seconds B. 90 seconds C. 120 seconds D. 45 second

A. 15 seconds The nurse would rub the hands together until they are dry, for at least 15 seconds. Drying ensures the antiseptic effect.

When adding sterile items to a sterile field, the nurse would drop the sterile items from which height? A. 6 in (15 cm) B. 10 in (25 cm) C. 2 in (5 cm) D. 14 in (35 cm)

A. 6 in (15 cm) When adding sterile items to a sterile field, the item is dropped from a height of 6 in (15 cm).

The nurse has just successfully inserted an intravenous (IV) catheter and initiated IV fluids. Which items should the nurse document? Select all that apply. A. Client's reaction to the procedure B. Rate of the IV solution C. Gauge and length of the IV catheter D. Location of the IV catheter access E. Manufacturer of the IV catheter F. Type of IV solution

A. Client's reaction to the procedure B. Rate of the IV solution C. Gauge and length of the IV catheter D. Location of the IV catheter access F. Type of IV solution The nurse should document the location where the IV access was placed, as well as the size of the IV catheter or needle, the type of IV solution, the rate of the IV infusion, and the use of a securing or stabilization device. Additionally, document the condition of the site. Record the client's reaction to the procedure and pertinent client teaching, such as asking the client to alert the nurse if the client experiences any pain from the IV or notices any swelling at the site. Document the IV fluid solution on the intake and output record.

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

A. Confirm the client's identity After performing hand hygiene, the nurse would confirm the client's identity. The nurse would then ensure that the work surface is at waist height and place the package in the center of the surface. Lastly, the nurse would open the outside cover of the package and remove the kit.

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

A. Drop the item from 6 in (15 cm) above the sterile field. Dropping the item from roughly 6 in (15 cm) above the surface prevents contamination of the field or dropping the item too close to the 1-in (2.5-cm), nonsterile border. Removing the gauze with one sterile hand risks contamination of that hand. It does not extend the sterile field to lay an unsterile package to the outside of the 1-in (2.5-cm) border.

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? A. The glove ends extend to cover the gown's cuffs. B. The edges of the gloves are under the gown's cuffs. C. There is a 1-in (2.5-cm) space between the gown's cuffs and the gloves' edges. D. The ends of the gloves are folded over onto the glove.

A. The glove ends extend to cover the gown's cuffs. When properly applied, the edges of the gloves should extend to cover the cuffs of the gown so that there is no visible skin exposed.

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

A. The inner surface of the outer wrapper is considered sterile. The outer wrapper of a pre-packaged kit is used to create the sterile field, such that the inner surface of the wrapper, which is sterile, becomes the sterile field once it is opened. The outside surface of the outer wrapper is considered contaminated. A 1-in (2.5-cm) border of the wrapper is considered contaminated. The wrapper is positioned on the work surface so that when it is flat, the edges are on the work surface and do not hang over the sides of the surface.

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? A. The nurse allows the drape to touch his or her body. B. The nurse touches the sterile drape by its corners. C. The nurse places the shiny side of the drape facing down. D. The nurse allows the drape to unfold gently.

A. The nurse allows the drape to touch his or her body. The drape becomes contaminated when it touches anything that is not sterile, such as the nurse's body clothing, or a non-sterile surface. Touching the drape by the corners and allowing it to unfold gently maintains sterility. The shiny or blue side is the moisture-proof side that prevents contamination of the field if it becomes wet

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

A. The specific items that the nurse transferred into a sterile field. 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 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? A. Unfasten the gown at the waist. B. Pull off both gloves at the cuff area. C. Untie the gown at the neck. D. Remove the glove from the dominant hand.

A. Unfasten the gown at the waist. When removing personal protective equipment, a gown that is tied in the front at the waist is unfastened first because the front of the gown, including the waist ties, are considered contaminated. The nurse would then remove the gloves, one at a time, so that one glove is contained within the other. After discarding the gloves, the nurse would then untie the gown at the neck and back.

The nurse uses soap and water for hand hygiene. Which action demonstrates proper handwashing? A. Using a rubbing, circular motion B. Washing to 1 in (2.5 cm) below the elbows C. Drying the hands, then fingers D. Keeping the hands above the elbows

A. Using a rubbing, circular motion When washing the hands with soap and water, the nurse would use a rubbing circular motion to wash the palms and back of the hands, each finger, the areas between the fingers and knuckles, and the wrists and forearms. Throughout the process, the nurse would keep the hands lower than the elbows to allow water to flow toward the fingertips. The nurse would wash to at least 1 in (2.5 cm) above the level of contamination or to 1 in (2.5 cm) above the wrists. When drying the hands, the fingers are dried first and the nurse then moves upward toward the forearms.

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? A. "The hospital says that I have to wear this gown to enter your room." B. "I am required to wear a gown for certain infections that are easily passed to others." C. "I have to protect my other hospitalized clients from getting an infection." D. "You have a sign on your door indicating that you have a transmissible infection."

B. "I am required to wear a gown for certain infections that are easily passed to others." The client needs a matter-of-fact response that does not make him or her feel dirty, guilty, or confused. The nurse teaches the client in a direct way that some infections are easier to spread, making additional precautions necessary for everyone's protection. It is dismissive to say it is policy or just that there is a sign on the door, and it is unkind to state that the nurse wears a gown to protect everyone else from the client.

A nurse would perform additional monitoring of the IV site and infusion according to facility policy for which client? A.A client who has fluid imbalances. B. A client who is receiving IV medications. C. A client who is dehydrated. D. A client who is unconscious.

B. A client who is receiving IV medications. The nurse should monitor the IV infusion every hour or per agency policy, but more additional monitoring is necessary if the client is receiving IV medications. This promotes the safe administration of IV fluids and medications.

A nurse demonstrates the correct use of hand hygiene using an alcohol-based handrub for which situation? Select all that apply. A. Before eating a meal B. After applying a clean, dry dressing C. After removing gloves D. After using the restroom E. Before entering a client's room

B. After applying a clean, dry dressing C. After removing gloves E. Before entering a client's room An alcohol-based handrub can be used if hands are not visibly soiled or have not come in contact with blood or body fluids. Appropriate situations would include before entering a client's room, after removing gloves, and after applying a clean, dry dressing. Soap and water should be used before eating and after using the restroom.

The nurse is monitoring an IV site for a client who reports that the needle feels "funny." What should the nurse do first? A. Remove the catheter and apply a gauze dressing. B. Check the integrity of the IV system, IV solution and tubing, and flow rate. C. Discontinue the IV infusion and notify the health care provider. D. Reassure the client that this is a normal feeling associated with an IV infusion.

B. Check the integrity of the IV system, IV solution and tubing, and flow rate. The nurse would first check the integrity of the IV system, IV solution and tubing, and validate the correct drip rate. Next, the nurse would assess the venous access for redness, edema, warmth, coolness, pallor, and pain. If any of these are present, the nurse would discontinue the IV, initiate a new venous access in a different site, and notify the health care provider.

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 is the best action by the nurse at this time? A. Document the findings in the client's medical record. B. Discontinue the therapy and assess the client. C. Notify the health care provider of the findings. D. Gently rub and massage the area to warm it up.

B. Discontinue the therapy and assess the client. The best action by the nurse at this time is to discontinue the therapy and assess the client; this should be done before notifying the health care provider or documenting the event. Gently rubbing the area or massaging it would not be appropriate at this time.

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? A. On each of the fingertips B. In the palm of one hand C. On the back of the non-dominant hand D. Between each finger

B. In the palm of one hand The proper procedure for using an alcohol-based handrub is to apply the appropriate amount of product to the palm of one hand. This helps to ensure that the product will cover all the surfaces when the product is rubbed in. The nurse would rub the hands together, covering all surfaces of hands and fingers, between fingers as well as the fingertips and the area beneath the fingernails. It would be inappropriate to apply the product to each fingertip, on the back of the hand, or between each finger.

When washing the hands with soap and water what is an appropriate action for the nurse to perform? A. Rub each hand with soap individually. B. Keep the hands below the elbows. C. Lean as close to the sink as possible. D. Remove jewelry prior to turning on water.

B. Keep the hands below the elbows. The nurse keeps the hands lower than the elbows to allow water to flow toward fingertips. When hand washing, the nurse washes jewelry, usually restricted to only a wedding band, before starting; jewelry can harbor microorganisms and contaminants. Next, the nurse would turn on the water, apply soap to the hands, and rub it in using a circular motion. After thoroughly cleaning the hands, the nurse would then clean under the nails. The nurse does not lean on the sink as this can lead to contamination.

The nurse prepares for a sterile procedure. What action does the nurse perform first? A. Put on personal protective equipment, if required. B. Perform hand hygiene with alcohol-based handrub. C. Place all the necessary supplies in the room. D. Identify the client the procedure is prescribed for.

B. Perform hand hygiene with alcohol-based handrub. Hand hygiene is done prior to donning any personal protective equipment, before entering the room, and before interacting directly with the client, such as checking the name on the armband.

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? A. Thrombus B. Phlebitis C. Infection D. Sepsis

B. Phlebitis 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. Infection, thrombus, and sepsis manifest as redness, pus, warmth, induration, and pain similar to phlebitis and may be caused by poor aseptic technique.

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 siderail. 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? A. Apply a new dressing and observe for signs of infection over the next several hours. B. Remove the IV catheter and reinsert another in a different location. C. Verify blood return, and then place a transparent dressing over the catheter hub, leaving the length of catheter open to air. D. Decontaminate the visible portion of the catheter, and then gently reinsert.

B. Remove the IV catheter and reinsert another in a different location. An IV catheter should not be reinserted. Whether the IV is salvageable depends on how much of the catheter remains in the vein. Because this catheter has been almost completely pulled out of the insertion site, it should be discarded and a new one inserted at a different location. It is not acceptable simply to apply a new dressing and leave the catheter sticking out of the site.

The nurse has just flushed a peripheral venous access site and notices fluid leaking from the insertion site. Which action is most appropriate? A. Attempt to flush the catheter again. B. Remove the IV catheter and restart the venous access site in a new location. C. Remove the dressing, ensure that all connections are tight, and apply a new dressing over the insertion site. D. Reinforce the original dressing and notify the health care provider.

B. Remove the IV catheter and restart the venous access site in a new location. Fluid leaking from the insertion site indicates that the catheter is not fully within the vein or that the catheter is cracked. The nurse should remove the catheter and restart the venous access site in a new location. Replacing or reinforcing the dressing will not stop the leaking, nor will flushing the catheter again.

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? A. Hand hygiene performance has been documented. B. The antiseptic has evaporated from the skin. C. Twenty to thirty seconds of hand rubbing has occurred. D. The hands have been dried with a paper towel.

B. The antiseptic has evaporated from the skin. Although products may vary, typically the nurse would apply the antiseptic to the palm of the hand, covering all surfaces of the hands and fingers. The nurse would continue to rub until the antiseptic until it evaporates from the hand. Hand hygiene is not documented. Thirty seconds may not be enough time for the solution to dry. Hands are not dried with a paper towel after using the alcohol-based handrub.

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

B. The nurse drops the item from the wrapper into the side of the sterile field. The outer edges of the sterile field are considered nonsterile. Dropping items into the outer edges of the field causes those items to be considered contaminated. Items are dropped toward the center of the field from approximately six inches above the surface of the field. The nurse opens the package outward over the hands, maintaining the sterility of the item inside the package. Items are typically held in the non-dominant hand while the dominant hand pulls the package open.

A group of students are demonstrating the skill for hand washing. What would indicate a need for additional teaching? A. The students use warm water to complete the hand washing skill. B. The students wash their hands for 15 seconds prior to drying them. C. The students rub their hands firmly with soap using a circular motion. D. The students keep their hands lower than their elbows throughout the skill.

B. The students wash their hands for 15 seconds prior to drying them. Hand washing is done for about 20 seconds, followed by a focus on the fingernails prior to rinsing off the soap. When performing hand washing, the water temperature should be warm to the touch. The hands should be kept lower than the elbows at all times to allow water to flow to the fingertips. Firm rubbing and a circular motion promotes friction that helps to loosen dirt and organisms that can lodge between the fingers, in skin crevices of the knuckles, on the palms and backs of the hands, and on the wrists and forearms.

The nurse wears personal protective equipment (PPE) when entering the client's room. What is the nurse's goal in wearing PPE? A. To prevent the client from touching the nurse B. To prevent infection transmission C. To adhere to facility policy D. To protect the client from the nurse's organisms

B. To prevent infection transmission The nurse's goal is to prevent infection transmission, including from other clients to this client and from this client to other clients. The nurse does not necessarily have an infection. The nurse is adhering to policy, but that is not the goal of using PPE during client care. The gown protects the nurse's other clients from an infectious organism, but the goal is not prevention of infection in the nurse, though that is a desirable outcome.

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

B. Unfold the top flap away from the body. When opening a sterile package prepared by a facility, the nurse would hold the package in the dominant hand with the top flap facing away from the body. The nurse would first unfold the top flap away from the body, then the side flaps (reaching under the package to open the opposite side flap), and lastly the flap closest to the body. The nurse would then pull the corners of the wrapper back toward the wrist.

The nurse is capping an existing IV line for intermittent use. Which action by the nurse follows correct procedure? A. attempting to aspirate for a blood return after flushing the extension tubing B. cleaning the end cap of the extension tubing with an antimicrobial swab C. flushing the extension tubing with a heparin solution to maintain patency D. loosely wrapping the extension tubing over the insertion site and tapes it in place

B. cleaning the end cap of the extension tubing with an antimicrobial swab The student nurse demonstrates understanding of the steps required for this procedure in cleansing the end cap of the extension tubing with an antimicrobial swab. Normal saline is used to flush the tubing, not a heparin solution, to maintain patency. The student nurse should have attempted to aspirate for a blood return before flushing the extension tubing. The extension tubing should be looped next to the insertion site, not wrapped over and taped on top of the insertion site.

When evaluating the effectiveness of sitz bath therapy, what outcome will the nurse expect? A. increased drainage from wound site B. increased comfort of client C. decreased need for dressing changes D. decreased anxiety of client

B. increased comfort of client The expected outcome for sitz bath therapy is that the client will verbalize an increase in comfort. Increased drainage, decreased need for dressing changes, and decreased anxiety are not expected outcomes for this type of therapy.

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? A. "It is not necessary to wear gloves for all client interactions." B. "The client is not on any precautions for infectious organisms." C. "Can you show me the hospital policy for when to wear gloves?" D. "I don't think gloves are needed to care for this particular client."

C. "Can you show me the hospital policy for when to wear gloves?" When there is any doubt, the facility resources should be consulted for verification of existing policies regarding transmission-based and standard precautions. This question prevents the nurse from arguing with the charge nurse, too. Gloves are not required for every client interaction.

A nurse gives a 13-year-old client an ice bag to place over a sprained ankle. How long should the nurse have the client apply the bag before the nurse removes it? A. 15 minutes B. 10 minutes C. 20 minutes D. 25 minutes

C. 20 minutes After 20 minutes, the nurse should remove the ice and dry the skin. Prolonged application of cold may result in decreased blood flow with resulting tissue ischemia.

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

C. Check the packages for expiration date. When setting up a sterile field, it is essential that the nurse check the packages for their expiration dates to ensure that the items are sterile. This must be done before opening any sterile items. The work surface should be placed at waist level before checking the expiration dates and opening any sterile packages. Sterile gloves are put on once the sterile field is set up.

Which hospitalized clients are good candidates for capping of an existing intravenous line for intermittent use? Select all that apply. A. Client who is tolerating the clear liquid diet without complication. B. Client who is solely receiving normal saline at 60 mL/hour. C. Client who no longer requires intravenous infusions. D. Client who needs infusions of an antibiotic only every 12 hours. E. Client who is only receiving fluids at a keep-vein-open rate.

C. Client who no longer requires intravenous infusions. D. Client who needs infusions of an antibiotic only every 12 hours. E. Client who is only receiving fluids at a keep-vein-open rate. The client who needs infusion of an antibiotic only every 12 hours is a good candidate for capping of an existing intravenous line for intermittent use, because the client now requires only twice daily infusions, not continuous infusions. The client who no longer requires IV infusions is a good candidate, because capping the line maintains IV access in case of an emergency; it is a typical hospital policy to do so. The client who is solely receiving fluids at a keep-vein-open rate is a good candidate for capping of an existing intravenous line, because continuous fluids are not needed to keep the vein open and the line patent. The client receiving a continuous infusion of normal saline at 60 mL/hour is not a good candidate, because the client still need continuous infusions. The client who is tolerating clear liquids is not a good candidate. The most common reasons for a client to be on a clear liquid diet is because the client recently had surgery, is experiencing nausea/vomiting, or has a bowel obstruction; in any of these cases, the client would need continuous infusions.

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? A. Review the medication record for use of antibiotics. B. Check with the other staff nurses on the unit. C. Consult the agency's infection control manual. D. Ask the health care provider about the client's condition.

C. Consult the agency's infection control manual. If there is a question about transmission-based precautions when caring for a client, the nurse should check the agency's infection control manual and the institution's policies about specific illnesses. Then the nurse should review the mode of transmission associated with the specific microorganism causing the illness. Although asking the health care provider about the client's condition and reviewing the medication record can provide additional information, the infection control manual and policies would be most appropriate to use. Checking with other staff nurses on the unit would be inappropriate because their actions could be inconsistent.

Which item would the nurse remove first when removing personal protective equipment? A. Mask B. Face shield C. Gloves D. Gown

C. Gloves When removing personal protective equipment (PPE), the first item to be removed is the gloves. If the gown is tied in the front, the nurse unties the gown first and then removes the gloves. The face shield is removed next, followed by the gown, and lastly the mask.

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? A. Toward the nurse's body B. To the right of the client C. On the far side of the package D. To the left of the nurse

C. 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 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? A. Pull the top cover off at an angle. B. Cut the package open with sterile scissors. C. Peel the edges apart with both hands. D. Tear open the package across the top.

C. Peel the edges apart with both hands. When opening sterile packages to be added to the sterile field, the nurse would hold the package in one hand and pull back the top cover with the other hand, or peel the edges apart using both hands. The package would not be torn or cut open, nor would the top cover be pulled off at an angle.

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? A. Document the observations in an incident report in the hospital's computer system. B. Report the occurrence to the unit's hiring manager for additional action. C. Reinforce teaching that transmission-based precautions must be observed. D. Ensure that the correct PPE is stocked by the room.

C. Reinforce teaching that transmission-based precautions must be observed. The new nurse may have forgotten, missed the signs, or some other honest error. The charge nurse first offers teaching to the new nurse immediately to prevent further potential harm. An incident report should not be necessary and is not an immediate action. The manager may need to be involved if the issue persists.

Personal protective equipment (PPE) is used in health care facilities for primarily which reason? A. To protect clients from becoming infected by staff members B. To protect the hospital from legal liability C. To protect both the staff and clients from becoming infected by one another D. To protect staff members from becoming infected by clients

C. To protect both the staff and clients from becoming infected by one another PPE protects both the staff from clients and the clients from staff. Although the use of PPE provides some protection for the hospital from legal liability, this is not the primary reason it is used.

The nurse is removing a gown after providing care to a client. Which action would the nurse take first? A. Turn the gown inside out. B. Pull the gown away from the torso. C. Unfasten the ties at the neck and back. D. Allow the gown to fall away from the shoulders.

C. Unfasten the ties at the neck and back. When removing a gown, the nurse first unfastens the ties at the neck and back, and then allows the gown to fall away from the shoulders. Touching only the inside of the gown, the nurse pulls the gown away from the torso. Keeping the hands on the inner surface of the gown, the nurse pulls the gown from the arms, turns it inside out, and folds or rolls it into a bundle to be discarded.

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? A. "Can you tell me why you did not observe policy?" B. "You have to observe policies like we all do." C. "Why did you enter the room without putting on a gown?" D. "I notice you did not wear the required PPE."

D. "I notice you did not wear the required PPE." It is incorrect to confront the provider in a confrontational or accusatory manner. Once the nurse states that this behavior has been observed, the nurse and provider can have a discussion.

What is the best source for the nurse to determine the type of transmission precautions a client needs? A. Health care provider B. Charge nurse's report C. Sign on the client's room D. Client's medical record

D. Client's medical record The client's medical record includes the type of precautions to observe and the laboratory reports to verify the organism. The sign on the client's room may be incorrect. Nurses typically ensure the client is on the correct precautions. The assigned nurse updates the charge nurse's report regarding transmission precautions.

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? A. Open the short extension tubing and prime with normal saline. B. Cleanse the access cap with an alcohol swab. C. Remove the primary IV tubing from the access cap. D. Close the clamp on the current administration set.

D. Close the clamp on the current administration set. After inspecting the site, the nurse should close off the clamp on the current administration set to prevent leaking of fluid when the set is removed. Following closure of the current administration set, the nurse should open the short extension tubing and close the clamp on that tubing to ensure air does not enter when priming, then remove the current tubing and cleanse the end cap or access cap before attaching the primed extension tubing

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? A. Apply an oil-free lotion to both hands. B. Use an alcohol-based handrub. C. Turn off the water at the faucet. D. Dry the hands with a paper towel.

D. Dry the hands with a paper towel. After rinsing the hands, the nurse would dry the hands using paper towels, wiping from the fingertips toward the forearms. Once dry, the nurse would then use another clean paper towel to turn off the water at the faucet to prevent clean hands from coming in contact with the soiled surface. The fingernails are cleaned before the hands are rinsed. The hands are dried using clean paper towel. An alcohol-based sanitizer or hospital-provided lotion can be used after handwashing and drying, if desired.

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? A. Mask B. Gloves C. Goggles D. Gown

D. Gown When using personal protective equipment (PPE), the nurse would put on the gown first. Then the nurse would then put on the mask and goggles, and lastly the gloves.

The nurse prepares to wear personal protective equipment (PPE) when entering a client's room. What action does the nurse take first? A. Verify the type of precautions. B. Ensure the gown is closed. C. Open the door to the room. D. Perform hand hygiene.

D. Perform hand hygiene. The nurse must perform hand hygiene before putting on gloves, just like any other time. The nurse does not want to introduce additional infectious organisms to this client. The client's door, for most isolation types, can be opened after PPE is on. Though often done incorrectly, when gowning it is important to ensure the gown covers the back and front of the nurse. As the nurse is dressing in PPE it is wise to double check that the correct transmission precautions are being observed and that each piece of equipment needed is being worn by the nurse. The nurse would not be wrong if wearing more than is required but would not want to wear less than is needed.

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? A. Pour the liquid into the cap of the bottle and dip the gauze as needed. B. Pour the liquid onto gauze on the sterile field until the gauze is moist. C. Pour the liquid into the palm of a sterilely gloved hand for use. D. Pour the liquid into a sterile container within the sterile field.

D. Pour the liquid into a sterile container within the sterile field. The liquid from a large container is poured into a sterile container present within the sterile field. The gauze is placed in this container if needed or moistened as desired for use. If gauze is laying on the field and the field become moist, it may be considered contaminated.

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? A. Insist the health care provider observe additional hand hygiene. B. Report the health care provider to the unit supervisor or manager. C. Ask the charge nurse to speak with the health care provider. D. Remind the health care provider about the transmission precautions.

D. Remind the health care provider about the transmission precautions. It is best to directly and immediately address the issue with the health care provider. The nurse may suggest that additional precautions are taken prior to entering the client's room, but really can't insist, and hand hygiene is expected for every client. The charge nurse or supervisor can intervene, following the chain of command, if the health care provider does not take corrective action.

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? A. Replace any items that moved with new ones. B. Add new sterile dressings to the sterile field. C. Ask the client if he touched anything. D. Set up an entirely new sterile field.

D. Set up an entirely new sterile field. The client came in contact with the sterile field. As a result, the sterile field is contaminated, and an entirely new sterile field must be created. Adding new sterile dressings to the sterile field would contaminate the new dressings because the sterile field is now contaminated. All the items need to be replaced. Asking the client if he touched anything would be inappropriate because the client's contact with the sterile field rendered it unsterile and it should not be used.

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? A. Sterile 4 × 4 gauze dressings, removed from the packaging and placed in the middle of the sterile field B. Sterile gloves, removed from the outer wrapping, 4 inches away from the edge of the sterile field C. Sterile drape hanging off the work surface D. Sterile drape positioned with the moisture-proof side facing up

D. Sterile drape positioned with the moisture-proof side facing up If the sterile drape is placed with the moisture-proof side up, it will become contaminated if it gets wet. Although any portion of a drape that hangs off the work surface is considered contaminated, it would not mean that the sterile field itself is contaminated. Sterile gauze being placed in the middle of the sterile field and sterile gloves being placed 4 inches away from the edge of the sterile field would not contaminate it, as these are proper procedures.

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

D. The field is contaminated if it is out of the nurse's site. When a pre-packaged kit is used to create a sterile field, it and everything it contains are considered sterile. The kit would become unsterile if the field is out of the nurse's site or if it was below waist level. Other sterile items can be added to the sterile field, and the nurse would need to wear sterile gloves to obtain any items from the field.

The nurse removes personal protective equipment after caring for a client on transmission-based precautions. Which action by the nurse is correct? A. Remove respirator at the doorway of the client's room. B. Remove the goggles before removing other equipment. C. Slide one gloved hand under the other glove for removal. D. Touch the inside of the gown and pull it away from the torso.

D. Touch the inside of the gown and pull it away from the torso. The outside of the equipment is considered contaminated. Removal follows a prescriptive sequence. Most personal equipment is removed at the door of the client's room. The contaminated glove grasps the other contaminated glove for removal. The nurse's clean hand reaches under the other glove for removal. Goggles are removed by holding the earpieces. Clean hands touch the inside of the gown for removal, pulling away from the torso. Roll these items up, inside out, for disposal. Grasp ties on mask on respirator for removal after leaving the room.

The nurse prepares to enter a client's room where goggles are required but are not available. Which action by the nurse is best? A. Wear a surgical mask and stay 3 ft (1 m) from the client. B. Wait until material management sends more goggles to the unit. C. Wait to administer client care until goggles can be located. D. Wear a face shield as part of the protective equipment.

D. Wear a face shield as part of the protective equipment. The nurse would not delay care due to a lack of goggles. The acceptable alternate is a face shield, which is a mask with a clear plastic covering for the eyes. If goggles are needed, the nurse would not enter the room without eye covering unless there was an emergent reason to do so. However, it is not correct to delay care until goggles can be obtained. This can take quite a long time. Even if the goggles can be supplied soon, the nurse can easily locate and use a face shield.

Place in order, from first to last, these actions the nurse will perform when providing wound care to a client with a pressure injury. Use all options. Time and date the dressing. Open dressing materials. Assess the wound bed. Put on clean gloves. Remove old dressing. Irrigate the wound bed.

Put on clean gloves. Remove old dressing. Assess the wound bed. Open dressing materials. Irrigate the wound bed. Time and date the dressing. The nurse should first put on clean gloves, then remove the old dressing, assess the wound bed and surrounding skin, change gloves, open dressing materials, provide the wound care including irrigating the wound bed, then time and date the dressing once completed.

A nurse is preparing to perform hand hygiene using an alcohol-based handrub. Place the following steps in the correct order. Use all options. Remove jewelry Rub the hands together, covering all surfaces of the hands and fingers Apply the product Ensure that the hands are dry Check the product label for the correct amount to use

Remove jewelry Check the product label for the correct amount to use Apply the product Rub the hands together, covering all surfaces of the hands and fingers Ensure that the hands are dry Remove any jewelry. Then the nurse would check the product label for the appropriate amount to use and then apply the product to the palm of one hand. Next, the nurse would rub the hands together covering all the surfaces of the hands and fingers, and between fingers as well as the fingertips and the area beneath the fingernails. Lastly, the nurse would rub the hands together until they are dry (at least 15 seconds).

The nurse is capping an intravenous (IV) line for intermittent use. Place in order how the nurse will perform these actions. Use all options. Scrub the needleless connector or end cap on the extension tubing with an antimicrobial swab. Flush the tubing slowly, over one minute, with a sterile saline filled syringe. Reclamp the extension tubing and loop it near the entry site, securing it with tape. Insert the saline flush syringe into the needleless connector or end cap on the extension tubing. Aspirate the catheter for positive blood return by gently pulling back on the syringe.

Scrub the needleless connector or end cap on the extension tubing with an antimicrobial swab. Insert the saline flush syringe into the needleless connector or end cap on the extension tubing. Aspirate the catheter for positive blood return by gently pulling back on the syringe. Flush the tubing slowly, over one minute, with a sterile saline filled syringe. Reclamp the extension tubing and loop it near the entry site, securing it with tape. When capping an IV line, the nurse begins by disinfecting the needleless connector or end cap on the extension tubing, vigorously scrubbing it with an antimicrobial swab, and then allowing it to dry. Next, the nurse should insert the saline flush syringe into the end cap and aspirate for a blood return to confirm patency before administering fluids or medications. After getting a blood return, the nurse should slowly flush the line with sterile saline over one minute, and then reclamp the extension tubing to prevent air from entering. Lastly, the nurse should loop the line near the entry site to prevent the weight of the tubing from dislodging the catheter and secure it with tape.

The nurse is preparing to perform handwashing. Place the following steps in the correct order. Use all options. Apply soap. Wet the hands and wrists. Turn the faucet off with a paper towel. Pat the hands dry with a paper towel. Turn on the faucet and adjust the force and temperature of the water. Wash the palms and backs of the hands for at least 20 seconds.

Turn the faucet off with a paper towel. Wet the hands and wrists Apply soap. Wash the palms and backs of the hands for at least 20 seconds. Pat the hands dry with a paper towel. Turn the faucet off with a paper towel. First, turn on the water and adjust force. Second, wet the hands and wrists. Third, use about 1 teaspoon of liquid soap from the dispenser or rinse a bar of soap and lather thoroughly. Fourth, with firm rubbing and circular motions, wash the palms and backs of the hands, each finger, the areas between the fingers, and the knuckles, wrists, and forearms. Continue this friction motion for at least 20 seconds. Fifth, pat the hands dry with a paper towel, beginning with the fingers and moving upward toward forearms, and discard it immediately. Sixth, use another clean towel to turn off the faucet.

Place in correct order the steps for removing a gown. Use all options. Touching only the inside of the gown, pull away from the torso. Discard the gown. Fold or roll the gown into a bundle. Unfasten the ties. Turn gown inside out. Keeping hands on the inner surface of the gown, pull gown from arms.

Unfasten the ties. Touching only the inside of the gown, pull away from the torso. Keeping hands on the inner surface of the gown, pull gown from arms. Turn gown inside out. Fold or roll the gown into a bundle. Discard the gown. To remove gown: Unfasten ties, if tied, at the neck and back. Allow the gown to fall away from shoulders. Touching only the inside of the gown, pull away from the torso. Keeping hands on the inner surface of the gown, pull gown from arms. Turn gown inside out. Fold or roll into a bundle and discard.

A group of nurses are reviewing information about asepsis. Which statement by the group demonstrates the need for additional review? A. "Turning a back to a sterile field maintains the sterility of the field." B. "Items below waist level are considered contaminated." C. "Any items coming into contact with a sterile field must be sterile." D. "Reaching over a sterile field."

A. "Turning a back to a sterile field maintains the sterility of the field." A sterile field becomes contaminated if the nurse turns his or her back to it. Any item that comes into contact with a sterile field must be sterile. Reaching over a sterile field contaminates the sterile field. Any items below waist level are considered contaminated.

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? A. Assess for pain, shortness of breath, and abdominal pressure. B. Tell the client that this is a life-threatening situation and that the health care provider will be called. C. Leave the wound open and notify the health care provider. D. Place the client in a sitting position to reduce pressure on the abdomen.

A. Assess for pain, shortness of breath, and abdominal pressure. When excessive drainage appears on the dressing, the nurse would first assess the client for pain, shortness of breath, and abdominal pressure, and then place the client in the supine position to reduce pressure on the abdomen. The nurse would then place a dry, sterile dressing on the wound site and assess vital signs, while reassuring the client that while the wound condition has changed, he/she is all right and the health care provider will be notified immediately.

Which are basic principles of surgical asepsis? Select all that apply. A. Avoid talking, coughing, sneezing, or reaching over a sterile field. B. Consider the outer 1-inch (2.5 centimeters) edge of a sterile field to be contaminated. C. Hold sterile objects at hip level or above. D. Only a sterile object can touch another sterile object. E. Forceps soaked in disinfectant can be used to add items to a sterile field. F. Never turn the back on a sterile field.

A. Avoid talking, coughing, sneezing, or reaching over a sterile field. B. Consider the outer 1-inch (2.5 centimeters) edge of a sterile field to be contaminated. D. Only a sterile object can touch another sterile object. F. Never turn the back on a sterile field. Never walk away from or turn the back on a sterile field. This prevents possible contamination while the field is out of the worker's view. Consider the outer 1-inch (2.5 centimeters) edge of a sterile field to be contaminated. Only a sterile object can touch another sterile object. Unsterile touching sterile means contamination has occurred. Avoid talking, coughing, sneezing, or reaching over a sterile field or object. This helps to prevent contamination by droplets from the nose and the mouth or by particles dropping from the worker's arm. Hold sterile objects above waist level. This will ensure keeping the object within sight and preventing accidental contamination. Use dry, sterile forceps when necessary. Forceps soaked in disinfectant are not considered sterile.

The nurse prepares the sterile tray for indwelling catheter insertion while wearing sterile gloves. The nurse then pulls the client's blankets away from the pelvis to begin catheter insertion. What action should the nurse take next? A. Change into a new pair of sterile gloves. B. Dispose of the catheter kit and begin again. C. Begin cleansing the meatus with antiseptic. D. Position the catheter kit closer to the client.

A. Change into a new pair of sterile gloves. The client must be prepared prior to preparing the catheter kit. The nurse must wear sterile gloves while preparing the sterile tray, because it involves opening sterile supplies. If the nurse then touches a non-sterile surface, like the client's blankets, the sterile gloves must be changed prior to continuing the procedure. The nurse does not need to reposition the kit at this time. The nurse is no longer sterile and cannot proceed with cleaning the client with sterile solution. Only the nurse's gloves are contaminated; the nurse does not need to dispose of the kit.

The nurse is collecting a wound culture from a client's puncture wound. What is the nurse's first step in the procedure? A. Clean the wound. B. Dress the wound. C. Document the procedure. D. Obtain the wound culture.

A. Clean the wound. To obtain a wound culture, the nurse would first clean the wound, then obtain the wound culture, redress the wound, and document the procedure when complete. Cleaning the wound removes previous drainage and wound debris, which could introduce extraneous organisms into the collected specimen, resulting in inaccurate results.

In which client would the application of an external heating pad be contraindicated? A. Client who has a wound that is bleeding. B. Client who has a wound that is infected. C. Client who has muscle spasms from tension. D. Client who has chronic arthritic pain.

A. Client who has a wound that is bleeding. The application of an external heating pad is contraindicated in clients with an actively bleeding wound, an acute sprain, or with a condition associated with acute inflammation. Heat application is recommended for all the other clients listed.

Which clients will the nurse recognize are at an increased risk of thermal injury when using an external heating pad? Select all that apply. A. Client who is an older adult. B. Client who has peripheral neuropathy. C. Client who is experiencing joint pain. D. Client who has diabetes. E. Client who has a spinal cord injury.

A. Client who is an older adult. B. Client who has peripheral neuropathy. D. Client who has diabetes. E. Client who has a spinal cord injury. Clients who are at an increased risk of thermal injury when using an external heating pad include those with diabetes (decreased sensation), spinal cord injury (decreased sensation), peripheral neuropathy (decreased sensation), and older adults (the normal aging process whereby the skin is thinner because of the loss of subcutaneous tissue). A client experiencing joint pain is not at an increased risk of thermal injury.

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. Stage 1 pressure injury C. Stage 2 pressure injury D. Unstageable, skin intact

A. Deep tissue injury The nurse should document this finding as a deep tissue injury. Deep tissue injuries are characterized by a purple or maroon localized area of discolored intact skin or blood-filled blister caused by damage to underlying soft tissue from pressure and/or shear. The description of stage 1 pressure injury includes intact skin with non-blanchable redness. In a stage 2 pressure injury, the skin would not be intact, and there is partial-thickness skin loss involving epidermis, dermis, or both. An unstageable pressure injury has slough, which is a yellowish stringy substance attached to the wound bed, or eschar, which is black or brown necrotic tissue covering the wound, which prevents knowledge of the depth of the wound.

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? A. Dehiscence. B. Undermining. C. Sinus tract. D. Ecchymosis.

A. Dehiscence. Dehiscence is the term for the accidental separation of wound edges, especially a surgical wound. Ecchymosis is discoloration of an area resulting from the infiltration of blood into the subcutaneous tissue. A sinus tract is a cavity or tunnel underneath a wound that has the potential for infection, and undermining occurs when there are areas of tissue destruction underneath intact skin along the margins of a wound.

The nurse is assisting a client with a sitz bath. Which actions should the nurse perform? Select all that apply. A. Ensure that the call bell is within reach. B. Slowly unclamp the tubing and allow the sitz bath to fill. C. Hang the bag of tepid to warm water at the client's chest height on an IV pole. D. Have the client soak for about 50 to 60 minutes. E. Fill the bowl of the sitz bath about halfway full with tepid to warm water. F. Insert tubing into the infusion port of the sitz bath.

A. Ensure that the call bell is within reach. B. Slowly unclamp the tubing and allow the sitz bath to fill. E. Fill the bowl of the sitz bath about halfway full with tepid to warm water. F. Insert tubing into the infusion port of the sitz bath. The nurse should fill the sitz bath about halfway full with tepid to warm water, fill a bag with the same temperature water, insert the tubing from the bag into the infusion port of the sitz bath, and slowly unclamp the tubing and allow the sitz bath to fill completely. Tepid water can promote relaxation and help with edema; warm water can help with circulation. Filling the sitz bath ensures that the tissue is submerged in water. The call bell should be placed within reach because the client may become light-headed due to vasodilation and require assistance. The bag of water should be hung above the client's shoulder height, not at chest level. If the bag is hung lower, the rate of flow will not be sufficient, and water may cool too quickly. The client should be allowed to soak about 15 to 20 minutes, not 50 to 60 minutes.

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. A. Evidence of edema B. Distal pulses C. Skin color D. Respiratory rate E. Presence of sensation

A. Evidence of edema B. Distal pulses C. Skin color E. Presence of sensation Assessing for circulatory compromise includes assessing the skin color, assessing for distal pulses to the site, assessing for evidence of edema, and assessing for presence of sensation. While knowing the respiratory rate is good, it is not a part of assessing for circulatory compromise.

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. Grasp the outside of one glove with the opposite gloved hand. 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 is teaching a client the purpose of using an external heating pad. What should the nurse include in the teaching plan? Select all that apply. A. It helps to relieve pain from arthritis and joint stiffness. B. It can be used to treat inflammation, chronic pain, and surgical wounds. C. It promotes healing by decreasing perfusion to the site and decreasing edema. D. It promotes healing by accelerating the body's natural inflammatory response. E. It reduces the discomfort of muscle tension and muscle spasms.

A. It helps to relieve pain from arthritis and joint stiffness. B. It can be used to treat inflammation, chronic pain, and surgical wounds. D. It promotes healing by accelerating the body's natural inflammatory response. E. It reduces the discomfort of muscle tension and muscle spasms. The nurse should include in the teaching plan that using an external heating pad can promote healing by accelerating the body's natural inflammatory response, it reduces the discomfort of muscle tension and muscle spasms, it helps to relieve the pain from arthritis and joint stiffness, and it can be used to treat inflammation, chronic pain, and surgical wounds. Application of heat actually increases perfusion to the site by causing vasodilation.

Which assessment findings will the nurse use to determine the stage of a client's pressure injury? Select all that apply. A. No bone, tendon, or muscle visible. B. Full-thickness tissue loss C. Drainage is foul smelling and green in color D. Visible subcutaneous fat E. Skin around injury is red and warm to touch

A. No bone, tendon, or muscle visible. B. Full-thickness tissue loss D. Visible subcutaneous fat The assessment findings which will help the nurse determine the stage of a client's pressure injury are: subcutaneous fat is visible; there is full-thickness tissue loss; and no bone, tendon, or muscle is visible in the wound bed. This information should lead the nurse to document this as a stage 3 pressure injury. The skin being red and warm to the touch and the green foul drainage are indications of wound infection, but do not influence the staging of the client's pressure injury.

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. Obtain a new pair of sterile gloves. B. Continue with the dressing change. C. Place a new sterile glove over the ripped glove. D. Use the ripped glove for nonsterile actions.

A. Obtain a new pair of sterile gloves. 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 is caring for a client with an abdominal wound and prescriptions from the health care provider. Which prescription will the nurse initiate first? A. Obtain a sterile wound culture B. Consult dietician to assist client with meal choices C. Give ciprofloxacin 1gram IV every 12 hours D. Assist client up to chair three times daily

A. Obtain a sterile wound culture The nurse should first obtain the sterile wound culture. The culture should be obtained as soon as possible, because it takes time for the results to return and must be done before the nurse can start the ciprofloxacin. Antibiotics interfere with microorganism growth and the primary reason for obtaining a culture is to identify the cause of the infection. Identifying the invading microorganisms helps to determine treatment options and select the most appropriate treatment. The culture should be obtained while the client is in bed; therefore, it should be done before assisting the client up to a chair. Consulting the dietician to assist the client with meal choices should wait until the culture is obtained and the antibiotic is started, because it is of less importance to the well-being and safety of the client.

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. A. Pallor B. Redness C. Warmth D. Swelling E. Coolness

A. Pallor D. Swelling E. Coolness The nurse should inspect the tissue around the IV entry site for swelling, coolness, or pallor. These are signs of fluid infiltration into the tissue around the IV catheter. The nurse should also inspect the site for redness, swelling, and warmth. These signs might indicate the development of phlebitis or an inflammation of the blood vessel at the site.

The nurse is explaining the benefits of cold therapy to a client. What should the nurse include in the teaching plan? Select all that apply. A. Reduces swelling and inflammation B. Increases perfusion to the wound site C. Reduces bleeding and hematoma formation D. Slows the transmission of pain stimuli E. Causes blood vessels to dilate

A. Reduces swelling and inflammation C. Reduces bleeding and hematoma formation D. Slows the transmission of pain stimuli Because application of cold therapy causes vasoconstriction of the local blood vessels, the nurse should teach that the benefits include: decreasing the local release of pain-producing substances, thereby slowing the transmission of pain stimuli; reduces swelling and inflammation; and reduces the risk of bleeding and hematoma formation. Cold therapy does not increase perfusion or cause blood vessels to dilate.

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? A. Remove the bubbles by closing the roller clamp, stretching the tubing downward and tapping the tubing with a finger. B. Change the IV solution administration set immediately. C. Disconnect the tubing from the client to purge the air from the tubing. D. Make sure the flow clamp is open and that the drip chamber is approximately half full.

A. Remove the bubbles by closing the roller clamp, stretching the tubing downward and tapping the tubing with a finger. If the bubbles are above the roller clamp, the nurse can easily remove them by closing the roller clamp, stretching the tubing downward, and tapping the tubing with a finger so the bubbles rise to the drip chamber. Ensuring that the flow clamp is open and that the drip chamber is half full helps to promote fluid flow. It would not be necessary to change the administration set to troubleshoot this problem. Disconnecting the tubing from the client would be inappropriate and disrupt the integrity of the sterile IV administration system.

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? A. Replace the dressing with a larger one. B. Replace the dressing with a smaller one. C. Allow the wound to air dry. D. Notify the health care provider for further instructions.

A. Replace the dressing with a larger one. When replacing a dressing that has caused blisters on the underlying skin, the nurse would cleanse the area thoroughly, being careful not to aggravate the reddened and blistered areas, and could place a new, larger dressing over the wound so that the blistered area is not further aggravated by tape.

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? A. Rolling motion B. Up-and-down motion C. Back-and-forth motion D. Pushing motion

A. Rolling motion The nurse would insert the swab into the wound and gently roll it over the wound surfaces to obtain a sample of the pathogens causing the infection. Using a pushing motion, up-and-down motion, or back-and-forth motion will not provide the most accurate results according to evidence-based practice and may actually cause injury to the wound tissues.

The nurse is caring for a client with a pressure injury and is applying a saline-moistened dressing to the wound. What does the nurse understand to be the primary rationale for using a saline-moistened dressing? A. To promote moist wound healing and protect the wound from contamination and trauma. B. To fill the wound with saline to dissolve wound secretions. C. To prevent the dressing from sticking to the wound. D. To soften the dressing to prevent trauma to the wound bed.

A. To promote moist wound healing and protect the wound from contamination and trauma. Saline-moistened dressings are used to maintain a moist wound environment to promote moist wound healing and protect the wound from contamination and trauma. A moist wound surface enhances the cellular migration necessary for tissue repair and healing. It is important that the dressing material be moist, not wet, when placed in open wounds. Although a moist dressing may also prevent sticking to the wound, this is not its primary purpose.

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? A. To use if the first pair of sterile gloves gets contaminated B. To remove the existing dressing from the abdominal wound C. To leave in the room with additional supplies for the next change D. To be able to change gloves if the wound has copious draining

A. To use if the first pair of sterile gloves gets contaminated 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.

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? A. Use small amounts of sterile saline to help loosen and remove the dressing. B. Wipe the area with an alcohol wipe and pull the dressing from the skin. C. Soak the area with sterile water using gauze pads. D. Wipe the area with an antimicrobial swab and pull the dressing from the skin.

A. Use small amounts of sterile saline to help loosen and remove the dressing. If part of the dressing sticks to the skin, the nurse would use small amounts of sterile saline to loosen and remove the dressing. Sterile saline moistens the dressing for easier removal and minimizes damage and pain

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? A. When the IV is discontinued. B. When the IV is initiated. C. When the IV solution is changed. D. When the IV is infusing.

A. When the IV is discontinued. Bleeding at an IV site may be caused by anticoagulant medication and is most likely to occur 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. a sterile gauze dressing B. clear non-permeable occlusive dressing C. a transparent semi-permeable membrane dressing D. 2 × 2 gauze with foam tape

A. a sterile gauze dressing A sterile gauze dressing is the best choice for this client, as it will absorb the extra moisture caused by the diaphoresis. Once the diaphoresis is resolved, the dressing should be changed to a transparent semi-permeable membrane dressing (TSM). TSM dressings allow easy inspection of the IV site and, because they are semi-permeable, permit evaporation of moisture that accumulates under the dressing normally. Non-permeable dressings are not recommended, because they do not allow evaporation of moisture. A dressing with foam tape is not recommended, because it does not allow visualization of the site.

Which client will the nurse expect to be prescribed sitz baths? Select all that apply. A. client who had rectal surgery B. client after childbirth C. client who had a hip replacement surgery D. client who had surgery to the perineum E. client after repair of a femur fracture

A. client who had rectal surgery B. client after childbirth D. client who had surgery to the perineum A sitz bath can help relieve pain and discomfort for clients who have had surgeries to the pelvic, perineal, or rectal areas; therefore, the nurse would expect the client who had rectal surgery, the client after childbirth, and the client who had surgery to the perineum to be prescribed sitz bath therapy. The therapy would not be appropriate for a client after hip replacement or repair of a femur fracture.

What should the nurse assess before application of sitz bath therapy? Select all that apply. A. client's ability to sit for 15 to 20 minutes B. client's ability to ambulate to the bathroom C. client's perineal/rectal area D. client's need to void E. client's serum sodium levels

A. client's ability to sit for 15 to 20 minutes B. client's ability to ambulate to the bathroom C. client's perineal/rectal area D. client's need to void Before application of sitz bath therapy, the nurse should assess the client's ability to ambulate to the bathroom, ability to sit for 15 to 20 minutes, appearance of the perineal/rectal area for swelling, drainage, tenderness, and the client's bladder fullness and need to void. Electrolyte levels are not affected by sitz bath therapy.

Which action by the nurse is most important to ensure the client's safety when changing a peripheral venous access device dressing? A. placing the bed in the lowest position before leaving the room B. gathering all equipment before entering the client's room C. using a semi-permeable dressing to cover the site D. inspecting the access site for redness and inflammation

A. placing the bed in the lowest position before leaving the room While all actions are correct, the one that is most important to ensure the client's safety is to place the bed back into the lowest position before leaving the room. This action helps to prevent falls or injuries when the client is getting out of the bed. Using a semi-permeable dressing allows moisture to evaporate. Gathering all equipment before entering the client's room helps the nurse be prepared and organized. Inspecting the site allows the nurse to recognize complications early and address them as needed.

Place in order, from first to last, the actions the nurse will perform when applying a warmed moist compress. Use all options. Cover the site with a dry, clean bath towel. Squeeze out any excess solution. Gently mold the compress to the intended site. Assess the application site. Remove the compress from the warmed solution.

Assess the application site. Remove the compress from the warmed solution. Squeeze out any excess solution. Gently mold the compress to the intended site. Cover the site with a dry, clean bath towel. When applying a warmed moist compress, the nurse should first assess the site where the compress is to be applied and then remove the compress from the warmed solution and squeeze out any excess solution to prevent excess moisture from damaging the wound bed. The nurse should then apply the compress by gently molding the compress to the site and then asking the client if it feels too hot. Finally, the nurse would cover the site with a dry clean bath towel.

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? A. "I cannot do that because your health care provider only prescribed it for 30 minutes at a time." B. "Leaving it on for more than 30 minutes can cause complications such as tissue injury." C. "Since it is making you feel better, I will call the health care provider and ask to leave it on longer." D. "Ok, we can leave it on for about 10 more minutes then I will return to remove it."

B. "Leaving it on for more than 30 minutes can cause complications such as tissue injury." The best response by the nurse would be to teach the client why 30 minutes is the maximum amount of time that a warm compress should be left in place; therefore, the best response by the nurse is "Leaving it on for more than 30 minutes can cause complications such as tissue injury." Telling the client that it can't be done because of a health care provider's prescription does not aide in the client's understanding of the reason for the time limit. Agreeing to leave it on for longer than 30 minutes puts the client at risk of tissue injury, and telling the client the nurse will call to get the time extended shows a lack of understanding by the nurse of the rationale for the time limit.

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? A. Place clean gloves over the sterile gloves. B. Ask someone to raise the bed. C. Raise the bed using one finger. D. Take off the sterile gloves.

B. 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 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? A. Complete the care right up to the step of the missing item, then go get it. B. Call someone to bring in the necessary item to the client's room. C. Leave the client and the room to obtain the missing item. D. Skip the part of the care that requires the missing item.

B. Call someone to bring in the necessary item to the client's room. So as not to disrupt the prepared sterile field, when the nurse notices that an item is missing, the most appropriate action would be to call someone to bring the necessary item to the client's room. If the nurse leaves the room at any time to obtain an item, the sterile field is no longer considered sterile and an entirely new sterile field would need to be set up. Skipping the part of care that requires the missing item would be inappropriate.

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? A. Pour the chilled irrigating solution into the irrigation container. B. Date and reuse leftover irrigation solution within 24 hours. C. Shake the bottle of irrigating solution before pouring. D. Discard any irrigation solution remaining in the bottle.

B. Date and reuse leftover irrigation solution within 24 hours. After setting up a sterile field, if indicated, the nurse pours the warmed sterile irrigation solution into the sterile container. The nurse should date the solution bottle if any solution is leftover and use it within 24 hours. There is no need to shake the irrigating solution. The irrigating solution may be warmed for use but should never be chilled for use. Any solution remaining may be used, if kept in the sterile container, for up to 24 hours; therefore, the nurse should not discard the remaining solution.

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? A. Notify the health care provider of the findings and request prescription for an antibiotic. B. Discontinue current IV and relocate to new site. C. Document the findings and continue to closely monitor the site. D. Change the site dressing using aseptic technique.

B. Discontinue current IV and relocate to new site. Redness and inflammation indicate a complication such as infection or phlebitis. Once noted, the nurse should discontinue the current IV, then locate and initiate a new IV site. Changing the dressing will not address the complications found. The nurse would document the findings and the actions taken, but should also discontinue and relocate the IV, not simply continue monitoring. Monitoring the site without taking action to discontinue and relocate the site will not address the current complication and puts the client at risk of a worsening infection. The health care provider can be notified after the IV is discontinued and relocated.

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

B. Ensure the skin of the hands does not touch the outside surface of the glove. The glove surface is contaminated, and one of the goals of wearing gloves is decreasing contamination between client and nurse. The nurse does not touch the outer surface of the glove with bare skin. Using hand sanitizer on the glove is a needless and unhelpful step. The gloves and sterile field remnants can be disposed of separately. Optimally, the gloves need to be folded into each other for disposal to decrease contamination risk.

After 30 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 is the best action by the nurse? A. Leave the therapy on for 10 more minutes and return to remove it after that time. B. Explain that leaving cold therapy on for longer than 30 minutes can cause tissue necrosis. C. Assist the client to get out of bed and sit up in a chair for a short while. D. Explain to the client that this is not possible because of the health care provider's prescription.

B. Explain that leaving cold therapy on for longer than 30 minutes can cause tissue necrosis. The best response by the nurse is to explain the possible complications of leaving cold therapy in place for too long which includes that it can cause cell death and tissue necrosis. This response not only answers the client's question but teaches at the same time the rationale and reason for limiting the cold therapy. Leaving the therapy on for 10 more minutes' places the client as increased risk of tissue injury, assisting the client out of bed ignores the client's request, and using the health care provider's prescription as the reason displays lack of understanding by the nurse and does not aid the client in understanding the rationale for the time limit.

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. A. Tap the outside of the culture tube with the swab before placing it in the tube. B. Insert a swab into the wound. C. Place the swab in the culture tube when done. D. Touch the swab to the intact skin at the wound edges. E. Press and rotate the swab several times over the wound surfaces. F. Use the same swab for both wound sites.

B. Insert a swab into the wound. C. Place the swab in the culture tube when done. E. Press and rotate the swab several times over the wound surfaces The nurse should carefully insert the swab into the wound and then press and rotate the swab several times over the wound surfaces. After collecting the specimen, the nurse should place the swab back in the culture tube. The nurse should be careful to keep the swab and the inside of the culture tube sterile at all times. This means that the nurse should avoid touching the swab to intact skin at the wound edges or to the outside of the tube, as this would contaminate both the swab with organisms not in the wound and the areas that the swab touches with organisms found in the wound. A different swab, not the same, should be used for each wound site to prevent cross-contamination.

When irrigating an infected wound, which action by the nurse best helps to prevent contamination of the irrigation syringe? A. Cleaning the tip of the syringe with an alcohol wipe after each use B. Keeping the tip of the syringe at least 1 in (2.5 cm) above the wound C. Positioning the client to face away from the sterile supplies D. Directing the flow of irrigating solution from the top of the wound

B. Keeping the tip of the syringe at least 1 in (2.5 cm) above the wound The best way to prevent contamination of the irrigation syringe is to ensure it never comes in contact with the wound by keeping the tip of the syringe at least 1 in (2.5 cm) above the wound when irrigating the wound. Although the nurse should direct the flow of irrigation from the top of the wound downward, this is not to prevent contamination of the syringe. Positioning of the client is based on wound location not on preventing contamination of the syringe. Cleaning the tip with alcohol wipe after each use is not a recommended way to keep the syringe free of contamination.

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? A. Fill the wound with sterile saline gel and cover with a large transparent dressing. B. Loosely pack the dampened dressing material to prevent too much pressure on the wound bed. C. Instill 50 mL of normal saline into the wound and loosely cover with packing material. D. Insert rolled gauze into the wound; saturate it with povidone-iodine solution and cover with a moisture-impervious dressing.

B. Loosely pack the dampened dressing material to prevent too much pressure on the wound bed. Gently press to loosely pack the moistened gauze into the wound. Avoid overpacking the gauze; loosely pack to prevent too much pressure in the wound bed, which could impede wound healing. The nurse should not instill normal saline or fill the wound with sterile saline gel, as these will not be effective in keeping the wound moist. Inserting rolled gauze into the wound will likely put too much pressure on the wound bed.

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. Obtain a new pair of sterile gloves. B. Open the top and bottom folds completely. C. Reach under the package folds to open. D. Slide the gloves out of the package.

B. Open the top and bottom folds completely. 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.

The nurse changes a client's peripheral venous access dressing. Which nursing action is correct? A. Loop the intravenous tubing near the entry site and secure it under the access dressing. B. Press the chlorhexidine applicator against the skin using a back-and-forth motion. C. Apply an antibacterial ointment to all the skin area that will be covered with the dressing. D. Label the new dressing with the client's name, date of birth, and initials.

B. Press the chlorhexidine applicator against the skin using a back-and-forth motion. The nurse is correct in pressing the chlorhexidine applicator against the skin and applying it using a back-and-forth motion. The label should include the date and time the dressing was changed and the nurse's initials, not the client's name or date of birth. The nurse is correct in applying skin protectant to all the skin that would be covered by the dressing, but an antibacterial ointment is not used. Looping the IV tubing near the entry site and taping it in place is correct, but securing it under the access dressing can lead to increased infection or accidental removal of the IV catheter.

Which situation would warrant the need for the nurse to change a client's venous access dressing? A. The IV infusion rate has slowed. B. The skin around the site is wet. C. The tubing is looped near the site of entry. D. The client is complaining of pain at the site.

B. The skin around the site is wet. Dressing changes are completed according to facility policy and as necessary, based on nursing judgment and assessments findings that the site dressing is damp, loosened, or soiled. The wet skin around the site suggests that the dressing is damp and needs to be changed. A slowed infusion rate or pain at the insertion site would require further assessment to identify the source of the problems; furthermore, pain at the site would likely require changing the site. Typically, tubing is looped near the site of entry to prevent pulling on the IV device.

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. Using the gloved dominant hand, grasp the glove of the non-dominant hand near the cuff on the outside. C. Slide the fingers of the gloved non-dominant hand between the skin and glove of the dominant hand. D. Pull on the fingertips of the gloved non-dominant hand using the fingers of the gloved dominant hand.

B. Using the gloved dominant hand, grasp the glove of the non-dominant hand near the cuff on the outside. 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 applying a warm compress, which client will benefit most from the application of moist heat instead of dry heat? A client who: A. needs relief from muscle tension and occasional spasms. B. requires that the heat penetrate deeply into the tissues. C. has chronic arthritic joint pain. D. has a wound with inflammation.

B. requires that the heat penetrate deeply into the tissues. The advantage of using moist heat instead of dry heat is that the moisture helps to soften crusted areas and penetrates the tissues more deeply than dry heat does. Therefore, the client who will benefit most from the use of moist heat instead of dry heat is the client who needs the heat to penetrate deeply. Like moist heat, dry heat also helps to relieve chronic arthritic pain, wound inflammation, and muscle spasms, and muscle tension; therefore, these clients would not benefit as much from moist heat as the other client.

Which client would be at greatest risk for developing a pressure injury? A. Adolescent client with a cast on the left leg B. Client who is delirious after taking pain medications C. Adult client who is comatose D. Older adult client who has chronic obstructive pulmonary disease (COPD)

C. Adult client who is comatose A client who is comatose is at greatest risk for developing a pressure injury due to the inability to turn or move in bed. This client needs to be turned regularly to prevent development of a pressure injury. The other clients have no restrictions for movement and would not be at great risk for developing a pressure injury. An older client who is bedridden (not a factor with COPD) would also be at high risk for developing a pressure injury due to age-related skin alterations.

The nurse knows that monitoring the infusion rate and IV site is a nursing responsibility. When does the nurse routinely monitor client IVs? A. End of the work shift. B. Upon discharge. C. Beginning of the work shift. D. Upon admission.

C. Beginning of the work shift. The nurse is responsible for monitoring the infusion rate and the IV site. This is routinely done as part of the initial client assessment and at the beginning of a work shift. In addition, IV sites would be checked at specific intervals and each time an IV medication is given, per the institution's policies.

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

C. Cleanse the central venous access device site while wearing sterile gloves. 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 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? A. Dry the wound bed using a sterile sponge. B. Open the culture tube and apply the swab to the wound bed. C. Cleanse the wound with a nonantimicrobial cleanser. D. Assess the drainage for amount, type, color, and odor.

C. Cleanse the wound with a nonantimicrobial cleanser. After removing the old dressing, discarding it, performing hand hygiene and applying fresh gloves, the nurse should cleanse the wound with a nonantimicrobial cleanser to prevent the culture from being contaminated by extraneous wound debris. The assessment of drainage for amount, type, color, and odor should have happened when the nurse removed the old dressing, because the old dressing is part of that information. The wound bed should be dried after the wound is cleaned, not before, and the nurse should not open the culture tube until the wound is cleansed and patted dry.

The nurse is positioning a client with a pressure injury to prepare to irrigate the wound. How would the nurse direct the flow of irrigation solution over the wound? A. From the right side of the wound to the left side B. From the left side of the wound to the right side C. From the upper end of the wound to the lower end D. From the lower end of the wound to the upper end

C. From the upper end of the wound to the lower end The nurse would position the client's wound so that the irrigation solution would flow from the upper end of the wound to the lower end. In this way, gravity directs the flow of the liquid from the least contaminated area of the wound to the most contaminated area, thereby decreasing the risk of wound contamination. Directing the flow of irrigating solution from the lower end to the upper end, or from one side to the other side, does not ensure that the solution flows from the least contaminated area to the most contaminated area.

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? A. Sealed IV dressing B. Occlusive dressing C. Gauze dressing D. Transparent semipermeable membrane dressing

C. Gauze dressing A gauze dressing is recommended if the client is diaphoretic or if the site is bleeding or oozing. However, the gauze dressing should be replaced with a transparent semipermeable membrane once this is resolved. Transparent semipermeable membranes are a type of sealed IV dressing. Occlusive dressings would not be appropriate.

Inspection of a client's peripheral venous access site reveals signs of phlebitis. Which action by the nurse would be most appropriate? A. Keep the IV in place, notify the health care provider, and start treatment for phlebitis. B. Discontinue the IV and start it at another site. If phlebitis worsens, notify the health care provider. C. Notify the health care provider, discontinue the IV, and start it at another site. D. Keep the IV in place until the solution has been infused, and then discontinue it and notify the health care provider.

C. Notify the health care provider, discontinue the IV, and start it at another site. When the nurse suspects phlebitis due to the findings of redness, swelling, and heat, the health care provider should be notified. The IV will need to be discontinued and restarted at another site. The health care provider should be notified immediately, not just if the phlebitis worsens.

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? A. Heat B. Edema C. Pallor D. Redness

C. Pallor The nurse inspects the site for swelling, leakage, and coolness or pallor, which may indicate infiltration. When this happens, the catheter may become dislodged from the vein, and IV solution may flow into subcutaneous tissue. Heat, redness, and slight edema may indicate sepsis, phlebitis, or thrombus.

The nurse has finished cleaning a client's surgical wound. What would be the nurse's next action in this procedure? A. Measure the length, depth, and width of the wound. B. Position the client to promote drainage of the solution. C. Pat the wound dry with a sterile gauze sponge. D. Allow the wound to air dry for 2 minutes.

C. Pat the wound dry with a sterile gauze sponge. The next step after cleaning a client's wound is to dry the wound with a sterile gauze sponge in the same manner in which it was cleaned, moving from top to bottom and from the inside to the outside of the wound. Moisture provides a medium for the growth of microorganisms. The nurse should not air dry the wound but pat it dry with a sterile gauze. Measuring the wound should happen after removing the old dressing. At that time the nurse should assess the wound, wound bed, drainage, and measure the wound. Positioning of the client should happen before beginning the procedure.

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? A. Change the dressing using sterile technique B. Notify the health care provider of the bleeding C. Reinforce the dressing and assess site frequently D. Call a rapid response and stay with the client

C. Reinforce the dressing and assess site frequently 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. Because this is the first surgical dressing that was applied by the surgeon, only the surgeon should change the dressing. Bleeding is expected and, therefore, the health care provider does not need to the notified. Calling a rapid response is not needed in this situation.

While performing a sterile dressing change, the nurse inadvertently contaminates the right-hand glove. Which action by the nurse would be most appropriate? A. Cover the contaminated glove with a non-sterile disposable glove B. Apply a new pair of sterile gloves over the current ones. C. Replace the current gloves with a new set of sterile gloves. D. Continue the procedure using only the left gloved hand.

C. Replace the current gloves with a new set of sterile gloves. If gloves become contaminated at any time, the nurse should remove the gloves and put on a new pair of sterile gloves. Using only the left hand, applying a new pair of gloves over the current pair, or covering the contaminated glove with a non-sterile one would be inappropriate.

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? A. Pounding headache. B. Deceased blood pressure. C. Shortness of breath. D. Change in the level of consciousness.

C. Shortness of breath. Fluid overload is caused when too large a volume of fluid infuses into the circulatory system. This complication manifests as engorged neck veins, shortness of breath and abnormal breath sounds (suggesting respiratory failure), increased blood pressure, and difficulty breathing. A pounding headache is a sign of speed shock and the change in level of consciousness is related to the existence of an air embolus.

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? A. Waterproof pad B. Used wound dressing C. Sterile basin D. Gauze

C. Sterile basin When irrigating a client wound, the nurse would place a sterile basin under the wound to protect the client and bed linens from the contaminated solution. The used wound dressing should be immediately discarded after removal and not used to collect solution, because this dressing is contaminated. A waterproof pad would not be used to collect the solution but may be used underneath the basin in case of splashes or spills to prevent soiling the bed linen. Gauze is not used to collect irrigating solution, this would be an expensive choice and does not protect the bed linen.

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? A. Administer the prescribed PRN analgesic. B. Notify the health care provider of the client's report of increased discomfort. C. Stop the heat application and completely remove the compress. D. Document the event in the client's medical record.

C. Stop the heat application and completely remove the compress. When the nurse observes increased maceration of the skin and the client reports increasing discomfort, the nurse should first stop the heat application and completely remove the compress. Only after this should the nurse complete the assessment of the site and obtain vital signs. Then the nurse should notify the health care provider, follow any prescription obtained and document the event.

Which includes practices used to render and keep objects and areas free from microorganisms? A. Medical asepsis B. Clean technique C. Surgical asepsis D. Hand hygiene

C. Surgical asepsis This statement describes surgical asepsis, or sterile technique. Medical asepsis, or clean technique, involves procedures and practices that reduce the number and transfer of pathogens. Hand hygiene is a type of medical asepsis specific to the hands and includes hand washing and use of alcohol-based handrubs.

The nurse prepares for a sterile dressing change on one end of the table by opening a sterile field and dropping the supplies onto it. The nurse needs to gather additional supplies remaining on the other side of the table. What action does the nurse take? A. Reach toward the other end of the table and pick up the supplies. B. Discard the current sterile field and supplies and begin again. C. Take a few steps around the table to pick up the additional supplies. D. Prepare a second sterile field to cover the entire table surface.

C. Take a few steps around the table to pick up the additional supplies. The nurse can step around the edge of the table, without turning his or her back on the sterile field, to gather the remaining supplies. Reaching across the current sterile field would be a reason to discard all the supplies and the field due to contamination. The table does not need to be completely covered with sterile drapes.

The nurse is preparing to clean a client's surgical wound. What would the nurse assess before beginning the procedure? A. The client's temperature and pulses B. Color of drainage on the wound dressings C. The client's comfort and effectiveness of pain medication D. Any physical limitations the client may have

C. The client's comfort and effectiveness of pain medication Prior to cleaning a client's wound, the nurse would assess the client's level of comfort and the need for analgesics before wound care. Wound care may cause pain for some clients. The color of any drainage on wound dressings would be assessed during the wound care procedure. Assessing physical limitations, temperature, and pulses may be appropriate, but these assessments are not directly related to the procedure for cleaning a wound. The procedure for cleaning the wound is the same for a client with or without physical limitations.

The nurse is putting on sterile gloves. Which principle would be important to keep in mind? A. The inner package should be placed on the surface with the cuff side away from the body. B. The outer edge of the cuff is used to pick up the glove to be put on. C. The hands should remain above waist level at all times. D. The cuffs of the gloves should be adjusted as each glove is applied.

C. The hands should remain above waist level at all times. When putting on sterile gloves, the nurse must ensure that the hands remain above waist level at all times. The inner package should be placed on the surface with the cuff side toward the body. The inner aspect of the cuff is used to put on the glove for the dominant hand, while the gloved fingers are slid under the cuff of the second glove to apply it. The cuffs are adjusted once both gloves are on.

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

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

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? A. Cleanse the area with an antimicrobial wipe prior to applying the new dressing. B. Cleanse the area with an alcohol wipe prior to applying the new dressing. C. Use Montgomery straps instead of adhesive tape to hold the dressing in place. D. Use a skin barrier on the wound itself prior to applying a dressing.

C. Use Montgomery straps instead of adhesive tape to hold the dressing in place. When a client's skin around a wound has been irritated by frequent removal of tape, the nurse would consider using 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). Alcohol wipes or antimicrobial wipes would not be used, as they would further irritate the skin.

The nurse is irrigating a client's pressure injury. How would the nurse know when to stop irrigating the wound? A. When the solution from the wound flows out a red color B. When all the irrigation solution is finished C. When the solution from the wound flows out clear D. When the solution from the wound flows out a pink color

C. When the solution from the wound flows out clear The nurse knows to stop irrigating a wound when the solution from the wound flows out clear. The irrigation removes the exudate and debris, which turns the solution from the wound red to pink to clear, when finished. It is not necessary to use all the solution if the flow is clear already. The nurse should not stop when the return flow is red or pink, this color indicates the wound has not been thoroughly cleaned or irrigated yet.

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: A. distal to proximal using a new gauze for each wipe. B. outside to center using a new gauze for each wipe. C. top to the bottom using a new gauze for each wipe. D. side to side using a new gauze for each wipe.

C. top to the bottom using a new gauze for each wipe. The nurse would clean the wound from the top to the bottom and from the center to the outside using a new gauze for each wipe. This method ensures that the cleaning is from the least to the most contaminated area and a previously cleaned area is not contaminated again. Cleaning from outside to center, from side to side, or from distal to proximal increases the risk of contaminating the wound as the nurse is starting in the most contaminated area and cleaning into the wound.

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? A. 100°F to 104°F (37.7°C to 40°C) B. 90°F to 99°F (32.2°C to 37.2°C) C. 110°F to 115°F (43.3°C to 46.1°C) D. 105°F to 109°F (40.5°C to 43°C)

D. 105°F to 109°F (40.5°C to 43°C) The nurse should set the external heating pad in the 105°F to 109°F (40.5°C to 43°C) range, which is physiologically effective and comfortable for the client. Lower temperatures are not as effective, and higher temperatures may cause damage to the underlying skin and tissues.

Which client is a greatest 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. 84-year-old client diagnosed with a urinary tract infection who frequently gets out of bed without calling for assistance D. 47-year-old client with severe alcoholism and a traumatic brain injury resulting in unconsciousness

D. 47-year-old client with severe alcoholism and a traumatic brain injury resulting in unconsciousness The 47-year-old client with severe alcoholism (poor nutritional status) and a traumatic brain injury (immobile) is at greatest risk for developing a pressure injury. The 17-year-old does not have any noted risk factors, the 25-year-old is young and only on bedrest for 24 hours so is very unlikely to develop a pressure injury, and the 84-year-old is ambulatory, making them a low risk for a pressure injury. For the 84-year-old client, the greatest risk is for falls.

Which client would be at highest risk for experiencing fluid overload as a complication of IV therapy? A. An adult injured in a car accident receiving medication via an IV infusion. B. A teenager receiving an IV infusion for dehydration. C. An infant receiving an IV infusion for bronchitis. D. An older adult client receiving an IV infusion for pneumonia.

D. An older adult client receiving an IV infusion for pneumonia. Although any client receiving IV therapy could develop fluid overload, older adult clients are more at risk for fluid overload due to the possible decrease in cardiac and/or renal functions.

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? A. Check the IV connector to ensure the clamp is closed. B. Lower the height of the pole. C. Attempt to flush the IV with 5 to 10 mL saline in a syringe. D. Check the electronic device for proper functioning.

D. Check the electronic device for proper functioning. If the electronic infusion is not running, the nurse would check the electronic device for proper functioning, make sure the flow clamp is open and that the drip chamber is approximately half full, and check the IV site for problems with the catheter. If the IV is free flowing, the nurse would raise the height of the IV pole. The nurse could also attempt to flush the IV with 1 to 3 mL of saline in a syringe.

The nurse is donning a pair of sterile gloves. The nurse correctly dons the first glove, but inadvertently inserts the thumb and index finger into the thumb hole of the second glove. The glove remains intact. Which action is most appropriate? A. Use only the correctly gloved hand to perform the sterile procedure while making sure the other hand does not contaminate the sterile field. B. Leave both the thumb and finger in the thumb hole and perform the procedure to the best of the nurse's ability. C. Don a second pair of sterile gloves over the first pair. D. Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole.

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

An older adult woman has been in the hospital for more than 1 week. While assessing her intravenous catheter port, the nurse finds a staph infection, which has developed in the past day or so. This infection is an example of which type of infection? A. Droplet infection B. Respiratory infection C. Sexually transmitted infection D. Health care-associated infection

D. Health care-associated infection This infection is best described as a health care-associated infection. A health care-associated infection is an infection not present on admission to health care agency and that has been acquired during the course of treatment for other conditions. The other terms listed do not apply to this infection.

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? A. An additional pair will be needed if the client reveals a previously undisclosed sexually transmitted infection. B. Unfamiliar supplies and equipment may frighten the client, so demonstrating the use of sterile gloves before the procedure may make the client more compliant. C. If another staff member enters the room and volunteers to assist, sterile gloves are immediately available. D. If the first pair is contaminated and needs to be replaced, the nurse does not need to leave the room for a new pair.

D. If the first pair is contaminated and needs to be replaced, the nurse does not need to leave the room for a new pair. It is a good idea to bring an extra pair of gloves when gathering supplies, according to facility policy. That way, if the first pair is contaminated in some way and needs to be replaced, the nurse will not have to leave the procedure to get a new pair. None of the other answers is as good of a rationale for bringing an extra pair of gloves into a procedure.

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

D. Invert the glove as it is removed. Inverting the glove as it is removed is correct. 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.

When applying an external heating pad, which prescription from the health care provider would the nurse question? A. Use gauze to secure the heating pad to the site of application. B. Maintain the temperature between 105°F to 109°F (40.5°C to 43°C). C. Assess site frequently during application of the heating pad. D. Leave heating pad on for 40 to 45 minutes, then off for 2 hours.

D. Leave heating pad on for 40 to 45 minutes, then off for 2 hours. The nurse should question the prescription to leave the heating pad on for 40 to 45 minutes, because this is too long and could cause a rebound phenomenon. Using heat for more than 20 to 30 minutes can result in tissue congestion, vasoconstriction and increases the risk of tissue damage. All other prescriptions are recommended guidelines for use of a heating pad.

When putting on the second sterile glove, the nurse places the gloved thumb at which location? A. Under the fingers, as in a fist B. Close to the palm of the gloved hand C. Adjacent to the fifth finger D. Outward away from the gloved hand

D. Outward away from the gloved hand When putting on the second sterile glove, the nurse holds the gloved thumb outward away from the rest of the gloved hand. The remaining gloved four fingers are placed inside the cuff of the second glove to apply it to the ungloved hand. The other grasping positions are awkward and not attempted

The nurse is preparing to perform wound care. Which intervention should be implemented to protect the nurse from injury? A. Gather all necessary equipment. B. Maintain a sterile field. C. Position the client. D. Raise the bed to elbow height.

D. Raise the bed to elbow height. The nurse would adjust the bed to a comfortable working position, usually elbow height. Having the bed at the proper height prevents back and muscle strain for the nurse. Maintaining a sterile field prevents risk of infection for the client. Positioning the client is to make the wound accessible for care. Gathering equipment helps the nurse be organized, not prevent injury.

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? A. Assure that the packing material is completely saturated when placed in the wound. B. Use less packing material. C. Discontinue application of saline-moistened packing and apply a hydrocolloid dressing instead. D. Reduce the time interval between dressing changes.

D. Reduce the time interval between dressing changes. Allowing the dressing material to dry will disrupt healing tissue. Therefore, the time interval between dressing changes should be reduced to prevent the dressing from drying out. Too much moisture in the dressing may cause maceration. Shortening the time interval between dressing changes is more appropriate than increasing dressing moisture. There is no indication that too much packing material was used. A hydrocolloid dressing in not indicated.

The nurse is collecting a wound culture and has removed the current dressing and discarded it. What should the nurse do next? A. Identify the client using two client identifiers. B. Twist and break the seal on the culture tube. C. Assess and clean the wound per orders. D. Remove gloves and perform hand hygiene.

D. Remove gloves and perform hand hygiene. After removing the current dressing and discarding it, the nurse should remove the gloves and perform hand hygiene. Then the nurse should apply fresh gloves; sterile gloves may be indicated if the wound edges must be separated to insert the culture swab. After hand hygiene and applying fresh gloves, the nurse would assess and clean the wound using a non-antimicrobial cleanser such as sterile saline, open the culture tube, obtain the culture and complete the procedure. Identifying the client using two client identifiers should happen before the procedure is begun along with explaining the procedure to the client.

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. Hold the second glove in the palm of the gloved hand. C. Use the thumb and index finger to grasp the cuff. D. Slide the gloved fingers under the cuff of the second glove.

D. 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 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 2 pressure injury B. Deep tissue injury C. Unstageable, skin intact D. Stage 1 pressure injury

D. Stage 1 pressure injury This finding should be documented as a stage 1 pressure injury. The description of stage 1 pressure injury includes intact skin with nonblanchable redness. In a stage 2 pressure injury, the skin would not be intact, and there is partial-thickness skin loss involving epidermis, dermis, or both. Deep tissue injuries are characterized by a purple or maroon localized area of discolored intact skin or blood-filled blister caused by damage to underlying soft tissue from pressure and/or shear. An unstageable pressure injury has slough, which is a yellowish stringy substance attached to the wound bed, or eschar, which is black or brown necrotic tissue covering the wound, which prevents knowledge of the depth 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. Prescribe the client a high carbohydrate diet to promote healing. B. Remove the eschar by irrigating with sterile saline. C. Teach the client to reposition every 4 hours. D. Teach the client ways to relieve the pressure on the heel.

D. Teach the client ways to relieve the pressure on the heel. The best nursing intervention at this time is to teach the client ways to relieve the pressure on the heel to prevent further damage. Stable eschar serves as "the body's natural (biological) cover" and is only removed by health care provider order. Teaching the client to reposition is a good intervention, but the client should be taught to reposition at least every 2 hours. The client would need adequate protein to promote healing, not carbohydrate.

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

D. 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 determines that the sterile field has been contaminated when which action occurs? A. The nurse reaches around the sterile field. B. The field is above waist level. C. A sterile object falls within the 1-in (2.5-cm) border of the field. D. The nurse turns his or her back to the field.

D. The nurse turns his or her back to the field. A sterile field becomes compromised if the nurse turns away from it, if it drops below waist level, if an object falls onto or outside of the 1-in (2.5-cm) border of the field, or if the nurse reaches over the sterile field.

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? A. The kit is dry. B. The kit is unopened. C. The expiration date is not yet reached. D. The outer wrapper is disposed in an appropriate receptacle.

D. The outer wrapper is disposed in an appropriate receptacle. When using a pre-packaged kit to set up a sterile field, it is important that the nurse check the expiration date to make sure that it is still valid. It is also important to ensure that the kit is dry and unopened, indicating that the kit is still sterile. Although the outer wrapper is discarded in an appropriate receptacle, this step does not ensure that the contents of the kit are sterile.

During sitz bath therapy, a client reports feeling dizzy and lightheaded. What is the most likely rationale for this occasional effect from sitz bath therapy? A. The client's blood pressure has increased. B. The cool water has caused the client to become cold. C. The client's wound has begun bleeding. D. The warm water caused vasodilatation.

D. The warm water caused vasodilatation. Because of the application of warm water to the area, vasodilatation can occur, causing the client to feel dizzy or lightheaded. Because of this occasional effect from sitz bath therapy, the nurse should ensure the client's call bell is in reach and instruct the client to not attempt to stand without assistance. Sitz bath is done with warm water, and the client may become cold if the water is allowed to cool, but this should not cause dizziness or lightheadedness. If the client experiences vasodilatation from the warm water, the vasodilation would cause the blood pressure to decrease slightly, not increase. Bleeding is not a common occurrence from sitz bath therapy and therefore not the most likely reason.

The nurse is preparing to put on sterile gloves. When putting on the first glove, how does the nurse grasp the folded cuff? A. Thumb and fifth finger B. Index and second finger C. Second, third, and fourth fingers D. Thumb and forefinger

D. 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 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? A. Pull the client up in the bed very gently. B. Gently massage any reddened areas for several minutes. C. Keep the head of the bed elevated 35 degrees. D. Turn and reposition the client every 2 hours.

D. Turn and reposition the client every 2 hours. Pressure injuries are a result of unrelieved pressure that damages underlying tissues. Teaching the caregiver to turn and reposition the client every 2 hours is an important intervention to help prevent unrelieved pressure from causing pressure injury to tissues. Keeping the head of the bed elevated will help to prevent aspiration but does not prevent pressure injury. The caregiver should be taught how to use a draw sheet to lift the client and then move the client up in bed. The client should not be pulled, because this causes a shearing force which can easily injure tissue. Reddened areas should not be massage so this should not be taught to the caregiver.

The nurse has documented that a client has an unstageable pressure injury. Which statement best describes this type of wound? The wound: A. has bright red granulation tissue in the wound bed. B. has redness with partial thickness loss of dermis. C. has exposed bone, tendon, or muscle visible. D. has black brown eschar covering the top.

D. has black brown eschar covering the top. 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. A wound that has exposed bone, tendon, or muscle visible would be considered stage 4. A wound that has redness with partial thickness loss of dermis would be considered stage 2, and a wound with bright red granulation tissue in the wound bed would be considered healing, although there is not enough information to stage this wound.