Chapter 1: Aspesis and Infection Control (Taylor Skills)

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. 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. Pat the hands dry with a paper towel.

1) Turn on the faucet and adjust the force and temperature of the water. 2) Wet the hands and wrists. 3) Apply soap. 4) Wash the palms and backs of the hands for at least 20 seconds. 5) Pat the hands dry with a paper towel. 6) Turn the faucet off with a paper towel. 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.

Which are basic principles of surgical asepsis? Select all that apply. a. Never turn the back on a sterile field b. Consider the outer 1-inch (2.5 centimeters) edge of a sterile field to be contaminated c. Avoid talking, coughing, sneezing, or reaching over a sterile field d. Forceps soaked in disinfectant are considered sterile e. Only a sterile object can touch another sterile object f. Hold sterile objects above hip level

Never turn the back on a sterile field, Consider the outer 1-inch (2.5 centimeters) edge of a sterile field to be contaminated, Avoid talking, coughing, sneezing, or reaching over a sterile field, Only a sterile object can touch another sterile object 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.

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

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.

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. Ask someone to raise the bed. b. Take off the sterile gloves. c. Raise the bed using one finger. d. Place clean gloves over the sterile gloves.

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

The nurse is 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. Gown b. Gloves c. Goggles d. Mask

a. 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.

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

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 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. Remind the health care provider about the transmission precautions. b. Ask the charge nurse to speak with the health care provider. c. Report the health care provider to the unit supervisor or manager. d. Insist the health care provider observe additional hand hygiene.

a. 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.

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

a. The fact that sterile technique was used for a given procedure. 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 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 ends of the gloves are folded over onto the glove. c. The edges of the gloves are under the gown's cuffs. d. There is a 1 in (2.5 cm) space between the gown's cuffs and the gloves' edges.

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.

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 be able to change gloves if the wound has copious draining d. To leave in the room with additional supplies for the next change

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 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. Untie the gown at the neck. c. Remove the glove from the dominant hand. d. Pull off both gloves at the cuff area.

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. Keeping the hands above the elbows. c. Drying the hands, then fingers. d. Washing to 1 in (2.5 cm) below 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 group of nurses are reviewing information about asepsis. Which statement by the group demonstrates the need for additional review? a. "Items below waist level are considered contaminated." b. "Turning a back to a sterile field maintains the sterility of the field." c. "Any items coming into contact with a sterile field must be sterile." d. "Reaching over a sterile field contaminates the sterile field."

b. "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.

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

b. 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.

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

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

b. 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.

When washing the hands with soap and water what is an appropriate action for the nurse to perform? a. Remove jewelry prior to turning on water. b. Keep the hands below the elbows. c. Rub each hand with soap invidividully. d. Lean as close to the skin as possible.

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.

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. On the far side of the package c. To the left of the nurse d. To the right of the client

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

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

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.

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

b. 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 prepares for a sterile procedure. What action does the nurse perform first? a. Place all the necessary supplies in the room. b. Perform hand hygiene with alcohol-based handrub. c. Put on personal protective equipment, if required. 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.

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 into a sterile container within the sterile field. c. Pour the liquid into the palm of a sterilely gloved hand for use. d. Pour the liquid onto gauze on the sterile field until the gauze is moist.

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

b. 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.

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. Set up an entirely new sterile field. c. Add new sterile dressings to the sterile field. d. Ask the client if he touched anything.

b. 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 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 thumb and index finger to grasp the cuff. b. Slide the gloved fingers under the cuff of the second glove. c. Use the fingers to grasp the edges of the cuff of the second glove. d. Hold the second glove in the palm of the gloved hand.

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

b. The field is contaminated if it is out of the nurse's sight. 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 is putting on sterile gloves. Which principle would be important to keep in mind? a. The outer edge of the cuff is used to pick up the glove to be put on. b. The hands should remain above waist level at all times. c. The cuffs of the gloves should be adjusted as each glove is applied. d. The inner package should be placed on the surface with the cuff side away from the body.

b. 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.

When opening a pre-packaged kit to prepare a sterile field, which would be important to keep in mind? a. The outside surface of the outer wrapper becomes the sterile field. b. The inner surface of the outer wrapper is considered sterile. 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.

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

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

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

b. 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.

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

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.

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. Pull on the fingertips of the gloved non-dominant hand using the fingers of the gloved dominant hand. d. Slide the fingers of the gloved non-dominant hand between the skin and glove of the 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.

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. "The client is not on any precautions for infectious organisms." b. "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?" d. "It is not necessary to wear gloves for all client interactions."

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.

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

c. "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.

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

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

c. 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.

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. Check with the other staff nurses on the unit. b. Review the medication record for use of antibiotics. 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.

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

c. Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole. It is appropriate to adjust the gloves as long as the nurse only touches sterile surface to sterile surface. Leaving the thumb and finger in the thumb hole or only using the correctly gloved hand to perform the sterile procedure would not be appropriate, nor would donning a second pair of gloves, in this case.

The nurse 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. Turn off the water at the faucet. b. Apply an oil-free lotion to both hands. c. Dry the hands with a paper towel. d. Use an alcohol-based handrub.

c. 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.

Which item would the nurse remove first when removing personal protective equipment? a. Gown b. Mask c. Gloves d. Face shield

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.

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. If another staff member enters the room and volunteers to assist, sterile gloves are immediately available. b. An additional pair will be needed if the client reveals a previously undisclosed sexually transmitted infection. c. 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. 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 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.

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

c. 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.

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

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.

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. Prepare a second sterile field to cover the entire table surface. 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. Reach toward the other end of the table and pick up the supplies.

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 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 grasps the remaining flap of the wrapper and pulls back toward wrist. c. The nurse drops the item from the wrapper into the side of the sterile field. d. The nurse holds wrapped item in dominant hand to open, opening top flap away from body.

c. 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.

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 expiration date is not yet reached. c. The outer wrapper is disposed in an appropriate receptacle. d. The kit is unopened.

c. 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.

The nursing instructor observes the nursing student removing sterile gloves. Which action indicates the need for further teaching? a. The student reaches under the glove on one hand to peel the glove off of the other hand. b. The student uses one gloved hand to grab the outside surface of the other glove. 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.

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

c. 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 adhere to facility policy. b. To prevent the client from touching the nurse. c. To prevent infection transmission. d. To protect the client from the nurse's organisms.

c. 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.

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

c. 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 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. Position the catheter kit closer to the client. b. Dispose of the catheter and begin again. c. Begin cleansing the meatus with antiseptic. d. Change into a new pair of sterile gloves.

d. 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.

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

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

d. 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.

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

d. 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.

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. Sexually transmitted infection c. Respiratory 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.

What action does the nurse perform to remove gloves after performing a sterile procedure? a. Lay the first removed glove in the sterile field. b. Pull the glove off starting at the fingers. c. Place the first removed glove in the waste. 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.

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. Tear open the package across the top. d. Peel the edges apart with both hands.

d. 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 nurse prepares to wear personal protective equipment (PPE) when entering a client's room. What action does the nurse take first? a. Open the door to the room. b. Ensure the gown is closed. c. Verify the type of precautions. 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 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 drape hanging off the work surface. b. Sterile gloves, removed from the outer wrapping, 4 inches away from the edge of the sterile field. c. Sterile 4x4 gauze dressings, removed from the packaging and placed in the middle of the field. 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.

Which includes practices used to render and keep objects and areas free from microorganisms? a. Clean technique b. Hand hygiene c. Medical asepsis d. Surgical asepsis

d. 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 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 unfold gently. b. The nurse places the shiny side of the drape facing down. c. The nurse touches the sterile drape by its corners. d. The nurse allows the drape to touch his or her body.

d. 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.

The nurse determines that the sterile field has been contaminated when which action occurs? a. The field is above waist level. b. The nurse reaches around the sterile field. 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 preparing to put on sterile gloves. When putting on the first glove, how does the nurse grasp the folded cuff? a. Second, third, and fourth fingers b. Thumb and fifth finger c. Index and second finger 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.

Personal protective equipment (PPE) is used in health care facilities for primarily which reason? a. To protect staff members from being infected by clients b. To protect clients from becoming infected by staff members c. To protect the hospital from legal liability d. To protect both the staff and clients from becoming infected by one another

d. 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 prepares to enter a client's room where goggles are required but are not available. Which action by the nurse is best? a. Wait to administer client care until goggles can be located. b. Wear a surgical mask and stay 3 ft (1 m) from the client. c. Wait until material management sends more goggles to the unit. 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.