NURSING SKILLS EXAM II

The nurse works on a surgical unit. For which of the following patients would a nurse expect to perform a bladder scan? (Select all that apply.) A. A patient who had an indwelling urinary catheter removed 8 hours ago and voided 30 mL once since it was removed. B. A patient who complains she is having urinary incontinence and never had this problem before. C. A patient who is postoperative for urological surgery. D. A patient who was placed on diuretic therapy to reduce peripheral edema. E. A patient who reports a change in urine color.

A. A patient who had an indwelling urinary catheter removed 8 hours ago and voided 30 mL once since it was removed. B. A patient who complains she is having urinary incontinence and never had this problem before. C. A patient who is postoperative for urological surgery. A bladder scanner is used to assess bladder volume whenever inadequate bladder emptying is suspected, such as after the removal of indwelling urinary catheters, in the evaluation of new-onset urinary incontinence, and after urological surgery. Diuretic therapy is not an indication for a bladder scan. A change in urine color requires further assessment because it may be due to a change in medicine, or it could be due to hematuria, but it is not an indication of inadequate bladder emptying.

A small group of nursing students is giving a teaching presentation on the principles of surgical asepsis. Which of the following standards are appropriate to include in the presentation? (Select all that apply.) A. A sterile barrier that has been permeated by moisture must be considered contaminated. B. A sterile object or field out of the range of vision or an object held below a person's waist is considered contaminated. C. A sterile field or object cannot become contaminated by air. D. If there is any doubt about an item's sterility, the item is considered to be unsterile. E. All items used within a sterile field must be sterile.

A. A sterile barrier that has been permeated by moisture must be considered contaminated. B. A sterile object or field out of the range of vision or an object held below a person's waist is considered contaminated. D. If there is any doubt about an item's sterility, the item is considered to be unsterile. E. All items used within a sterile field must be sterile. A sterile surface that comes in contact with moisture must be considered contaminated. A sterile object or field out of the range of vision or an object held below a person's waist is considered contaminated. A sterile object or field becomes contaminated by prolonged exposure to air; stay organized, and complete any procedure as soon as possible. If there is any doubt about an item's sterility, the item is considered to be unsterile. All items used within a sterile field must be sterile.

The nurse is inserting an indwelling Foley catheter in a male patient. The nurse asks the patient to bear down as if to void and slowly inserts the catheter through the urethral meatus. The nurse advances the catheter and meets resistance. What is the nurse's best initial action at this time? A. Ask the patient to take slow deep breaths while inserting the catheter slowly. B. Withdraw the catheter and notify the health care provider. C. Apply more force to insert the catheter inward. D. Remove the catheter, apply more lubricant, and reinsert

A. Ask the patient to take slow deep breaths while inserting the catheter slowly. If there is resistance to catheter insertion, the nurse should have the patient take slow deep breaths to promote relaxation while inserting the catheter slowly. Another technique is to rest the nurse's arm against the patient's leg and ask him to relax. When the leg muscles begin to relax, the nurse may continue the insertion process. If there is persistent resistance to insertion, the patient may have an enlarged prostate. Then it is appropriate to notify the health care provider; a Coudé catheter, with a slightly curved end, may be needed to facilitate insertion.

When should you perform hand hygiene? (Select all that apply.) A. Before applying gloves to insert an IV. B. After documenting in the patient's electronic medical record. C. After moving a patient up in bed. D. Before assessing a patient's vital signs. E. Before touching clean linens.

A. Before applying gloves to insert an IV. C. After moving a patient up in bed. D. Before assessing a patient's vital signs. You should perform hand hygiene before putting on sterile gloves and before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices. You should perform hand hygiene after contact with a patient's intact skin (e.g., after assessing a patient's vital signs or moving a patient in bed). Unless the hands are visibly soiled, it is unnecessary to perform hand hygiene after documentation. If you touch an object that is not visibly soiled, such as clean linens, hand washing is unnecessary at that time.

The nurse is working in a busy emergency room. On entering station 1, the nurse dons a pair of clean disposable gloves. The nurse sees that the patient has a gunshot wound to the chest and is concerned there may be splattering of infectious materials. The nurse applies goggles, a mask, and a gown. What is this called? A. Following standard precautions. B. Using medical asepsis. C. Using surgical asepsis. D. Infection control to prevent a health care-acquired infection.

A. Following standard precautions. The nurse is demonstrating the use of standard precautions. Standard precautions are used to protect the nurse from potential contact with blood and body fluids. Because there is a risk of being splattered with infectious materials, the nurse should use gloves, mask, eye protection, and a gown. Standard precautions should become a routine part of her practice and thus be observed in every patient encounter. Medical asepsis (or clean technique), includes procedures used to reduce the number of and prevent the spread of microorganisms. Surgical asepsis (or sterile technique) includes procedures used to eliminate all microorganisms from an area. Health care-acquired infections are those that develop as a result of a stay or visit in a health care facility and that were absent at the time of admission.

The nurse is teaching the male patient and family caregiver about the advantages of a condom catheter. Which of the following should be included in the teaching? (Select all that apply.) A. It is relatively safe and noninvasive. B. It ensures complete bladder emptying. C. It is a convenient method of draining urine. D. It is used for male patients who are incontinent. E. It may remain in place for several weeks at a time. F. It carries less risk of developing a UTI than an indwelling catheter. Correct

A. It is relatively safe and noninvasive. C. It is a convenient method of draining urine. D. It is used for male patients who are incontinent.

Identify contributing factors to pressure injury formation. (Select all that apply.) A. Malnutrition. B.Middle age. C. Decreased sensory perception/mobility. D. Anemia. E. Excessive sweating. F. Ethnic background.

A. Malnutrition. C. Decreased sensory perception/mobility. D. Anemia. E. Excessive sweating.

It is a very busy day on the nursing unit. The nurse has several patient admissions and discharges. One of the patients under the nurse's care has a chronic pressure injury of the coccyx. Regarding this patient's care, what can the nurse delegate to the nursing assistive personnel? (Select all that apply.) A. Reporting redness of the patient's coccyx to the nurse B. Teaching the patient and family about risks of pressure injury development C. Reporting patient complaints of pain D. Turning the patient every 2 hours E. Assessing healing status of pressure injury F. Reporting patient changes such as development of a foul wound odor

A. Reporting redness of the patient's coccyx to the nurse C. Reporting patient complaints of pain D. Turning the patient every 2 hours F. Reporting patient changes such as development of a foul wound odor

Which of the following are symptoms of latex allergy? (Select all that apply.) A. Skin redness. B. Itching. C. Purulent drainage. D. Edema. E. Difficulty breathing. F. Elevated temperature.

A. Skin redness. B. Itching. D. Edema. E. Difficulty breathing. Symptoms of latex allergy may vary in degree and may include redness and itching, hives, localized swelling, itchy or runny eyes and nose, coughing, rash, wheezing, bronchospasm, difficulty breathing, laryngeal edema, diarrhea, nausea, hypotension, tachycardia, and respiratory or cardiac arrest. Purulent drainage and elevated temperature may indicate infection.

The nurse is preparing a sterile field. Which of the following would be considered contamination of the field? (Select all that apply.) A. Some of the sterile normal saline spills onto the sterile barrier. B. Nonsterile items are added to the sterile field. C. The nurse prepares the sterile field and leaves the room to get more sterile supplies. D. The nurse prepares the sterile field immediately before the procedure. E. When a sterile item falls off the sterile field, the nurse opens a new sterile item.

A. Some of the sterile normal saline spills onto the sterile barrier. Correct B. Nonsterile items are added to the sterile field. Correct C. The nurse prepares the sterile field and leaves the room to get more sterile supplies. Correct

The nurse manager is reviewing the use of standard precautions with the staff. Which of the following should be included in the review? (Select all that apply.) A. Standard precautions are used to protect you from potential contact with blood and body fluids. B. Standard precautions should be observed in every patient encounter. C. Standard precautions refer only to the use of gloves, not to the use of masks, eye protection, or gowns; these refer to other types of precautions. D. To follow standard precautions, you must wear sterile gloves. Standard precautions are used once the type of infection is identified.

A. Standard precautions are used to protect you from potential contact with blood and body fluids. B. Standard precautions should be observed in every patient encounter. Standard precautions are used to protect you from potential contact with blood and body fluids and should be observed in every patient encounter. Besides gloving, standard precautions include the use of masks, eye protection, and gowns when there is a risk of being splattered with infectious materials. Surgical asepsis (sterile technique) requires the use of sterile gloves. Clean gloves may be worn when following standard precautions. Any patient may be a source of infection and should be treated as such rather than waiting until a pathogen is identified.

The nurse has a sterile urinary catheter and sterile gloves. Choose the remaining equipment the nurse will need to insert a straight urethral catheter: (Select all that apply.) A. Sterile cotton balls. B. Antiseptic solution. C. Sterile urinary collection bag. D. Water-soluble lubricant. E. Sterile forceps.

A. Sterile cotton balls. B. Antiseptic solution. D. Water-soluble lubricant. E. Sterile forceps. Straight urinary catheterization requires aseptic (sterile) technique. The nurse will need five to six sterile cotton balls soaked in antiseptic solution, such as Betadine, to reduce the number of microorganisms present on perineal area. Sterile forceps are used to pick up the antiseptic-saturated cotton balls. Water-soluble lubricant is used to ease insertion of the catheter. A sterile urinary collection bag is used for an indwelling catheter. Sterile water or normal saline in a syringe is used to inflate the balloon on an indwelling catheter and is unnecessary for a straight catheter.

The nurse is preparing to insert a urinary catheter. To perform this procedure, the nurse will use: A. Surgical asepsis (sterile technique). B. Medical asepsis (clean technique). C. Droplet precautions. D. Standard precautions.

A. Surgical asepsis (sterile technique).

The nurse is caring for four individuals. Which patient would be most at risk for infection? A. The patient who is receiving immunosuppressive medication. B. The patient who is unable to shower without assistance. C. The patient with a history of a latex allergy. D. The patient who exercises daily in a swimming pool.

A. The patient who is receiving immunosuppressive medication. The patient receiving immunosuppressive medication would have an impaired or delayed response to antigens and would be at increased risk for infection. This would include such medications as steroids and chemotherapeutic drugs. Contact sports places a patient at risk for certain infections. Hypoallergenic (latex-free) gloves can be used with patients who have an allergy to latex. Requiring assistance to bathe does not place the person at risk for infection. The patient may still receive hygienic care

The nurse is reviewing how to perform a bladder scan for determining postvoid residual (PVR) with nursing assistive personnel (NAP). Which of the following statements, if made by the NAP, indicates understanding? (Select all that apply.) A. "This test requires the patient to follow fluid intake restrictions." B. "I will measure and record the patient's intake and output." C. "I will perform the bladder scan and then have the patient urinate." D. "I will apply ultrasound gel above the patient's symphysis pubis." E. "I should point the scanner head downward toward the bladder."

B. "I will measure and record the patient's intake and output." D. "I will apply ultrasound gel above the patient's symphysis pubis." E. "I should point the scanner head downward toward the bladder." The NAP should measure and record intake and output (I&O) so urine trends can be assessed. Ultrasound gel is spread on the midline abdomen 2.5 to 4 cm (1 to 1.5 inches) above the symphysis pubis and light pressure is applied to the scanner head as it is pointed in a direction downward toward the bladder (following manufacturer's directions). The patient is instructed to empty the bladder before the scan. There is no restriction in fluid intake for a bladder scan.

Four patients had a bladder scan for PVR. For which of the following patients would further investigation be required? A. A patient with a PVR of 25 mL. B. A patient with PVR measurements of 125 mL and 150 mL. C. A patient with a PVR of 50 mL. D. A patient with a prescan volume of 250 mL and a PVR volume of 30 mL.

B. A patient with PVR measurements of 125 mL and 150 mL. A PVR volume of less than 50 mL is considered normal. Two or more PVR measurements greater than 100 mL require investigation. It would be an expected finding for a PVR volume to be less than the prescan void. Prescan volume is the amount of urine the patient voids attempting to empty the bladder completely before having a PVR measured by either bladder scan or straight catheterization.

During a sterile dressing change, when are the gloves changed? A. After the old dressing is removed and before creating a sterile field. B. After the old dressing is removed and before cleansing the wound. C. After the old dressing is removed, after cleansing the wound, and before applying a new dressing. D. It is unnecessary to change gloves for chronic wounds.

B. After the old dressing is removed and before cleansing the wound.

Which of the following are common sites for the development of pressure injuries? (Select all that apply.) A. Sternum. B. Heels. C. Sacrum. D. Lateral malleoli. E. Trochanters. F. Ischial tuberosities.

B. Heels. C. Sacrum. D. Lateral malleoli. E. Trochanters. F. Ischial tuberosities.

An elderly patient is admitted for back surgery. She is now retired but her previous occupation was as a registered nurse. She reports that she is also allergic to morphine and penicillin. She has a history of five laminectomies (back surgeries) resulting from scoliosis as a child. She has three children who visit her. She requires a cane to ambulate. Which factors would be considered high-risk factors for latex allergy? (Select all that apply.) A. Her age. B. History of multiple surgeries as a child. C. Allergy to morphine and penicillin. D. Occupation. E. Use of a cane.

B. History of multiple surgeries as a child. D. Occupation. High-risk factors for a latex allergy include a history of spina bifida, congenital or urogenital defects, indwelling catheter, placement or repeated catheterizations, adverse reactions during surgery or dental procedures, use of condom catheters, multiple childhood surgeries, food allergies (papaya, avocado, banana, peach, kiwi, tomato), and high latex exposure (e.g., housekeepers, food handlers, health care workers). This patient has the risk factors of a history of multiple surgeries and her previous occupation as a registered nurse, where she was often in contact with latex. These factors placed her at high exposure to latex in her past. Her age, known allergies, and the use of a cane are unrelated to a risk for latex allergy.

Which of the following actions associated with urinary catheterization could cause a potential problem? A. Attaching the bedside drainage bag to the bed frame. B. Keeping the foreskin retracted after catheterization. C.Failing to test the balloon by injecting fluid from prefilled sterile water syringe into the balloon port before insertion. D. Cleansing the far labial fold, the near labial fold, and directly over the center of urethral meatus using a new swab with each area.

B. Keeping the foreskin retracted after catheterization. Failure to reduce the foreskin after catheterization can result in paraphimosis (constriction of the foreskin). The bedside drainage bag should be attached to the bed frame and not the bed rails to avoid accidentally raising the rails (and the collection bag) above the level of the bladder, allowing reflux of urine. Testing the balloon by injecting fluid from the prefilled sterile water syringe into the balloon port is no longer a common practice. Testing the balloon may stretch the balloon and lead to damage, causing increased trauma on insertion. Cleansing the far labial fold, the near labial fold, and directly over the center of urethral meatus using a new swab with each area is the correct procedure for cleaning the female patient.

The nurse is preparing a sterile field. The nurse opens the sterile commercial kit by pulling the outermost flap toward his body, followed by opening the remaining flaps. The nurse touches only the outer edge of the sterile field with his hands. The nurse adds sterile items to the sterile field by placing them on the field at an angle and never allowing the wrapper to touch the field. The nurse pours normal saline form a previously opened bottle in the patient's room into a sterile receptacle without splashing. Which action(s) in preparing a sterile field did the nurse perform incorrectly? (Select all that apply.) A. The nurse correctly prepared the sterile field. B. Opening the outermost flap. C. Touching the outer edge of the sterile field. D. Adding sterile items to the field. E. Pouring a sterile solution.

B. Opening the outermost flap. Correct E. Pouring a sterile solution. Correct The technique described for opening the sterile commercial kit was incorrect because it would cause the nurse to reach over the sterile field to open the other flaps. The nurse should not pour solution from a previously opened bottle because sterility cannot be ensured. The outer 1-inch border is always considered contaminated, and it is appropriate for the nurse to have touched it. If the nurse had touched the inner portion of the sterile field, then sterility would be considered broken. The nurse added sterile items to the field correctly. By placing items onto the field at an angle, the arm never reaches over the field.

The nurse is reviewing with the surgical technician how to prepare a sterile field. Which of the following is incorrect and should not be included in the review? A. Keep your intended work surface above waist level. B. Place the drape so the top half of the drape is over the top half of the work surface. C. You may grasp the outer 1-inch border of the drape without wearing sterile gloves. D. Place sterile items onto the sterile field at an angle.

B. Place the drape so the top half of the drape is over the top half of the work surface. The sterile drape should be placed in a direction so the bottom half of the drape is over the top half of the intended work surface. This prevents the nurse from reaching over the sterile drape once it is on the table surface. The sterile field should be at or above waist level. There is a 1-inch border around any sterile drape or wrap that is considered contaminated. To avoid reaching over the sterile field, sterile items should be placed at an angle onto the sterile fiel

The nurse is assessing the patient's condom catheter. Which of the following most likely indicates the condom catheter should be removed? A .Patient complains of the leg bag feeling "heavy" while in bed. B. Redness and/or excoriation of the penis C. Patient's urine appears clear amber with ammonia smell. D. Less than 30 mL/hr of urinary output.

B. Redness and/or excoriation of the penis

Which task can be delegated to the NAP? A. Assesing the pts level of comfort B. Securing the dressing using surgical tape C. assesing the pt allergies to wound agents d. teaching the pt and family of wound dressing changing

B. Securing the dressing using surgical tape

The nurse is adding a dry sterile gauze dressing to the sterile field. The dressing bounces on the surface and lands on the outer 1-inch border of the sterile field. What action is appropriate at this time? A. The nurse discards the entire sterile field, all items on it, and starts over. B. The nurse opens another sterile gauze dressing and adds it to the sterile field, but does not use the first one. C. Once sterile gloves are applied, the nurse moves the sterile gauze dressing to the center of the sterile field. D. The nurse continues with the procedure adding supplies to the sterile field and using each of them as needed.

B. The nurse opens another sterile gauze dressing and adds it to the sterile field, but does not use the first one. The outer 1-inch border is considered contaminated; therefore, the gauze that landed on the outer 1-inch border is also considered contaminated and should not be used. It is unnecessary to dispose of the entire sterile field.

Identify prevention strategies for pressure injuries. (Select all that apply.) A. Reposition patient at least every 4 hours; use a documented schedule. B. When the patient is in the side-lying position in bed, use the 30-degree lateral position. t C. Place patient on a pressure-reducing support surface. D. Maintain the head of the bed at 45 degrees. E. Massage reddened bony prominences. F. Oral supplements should be instituted if the patient is found to be undernourished.

B. When the patient is in the side-lying position in bed, use the 30-degree lateral position. t C. Place patient on a pressure-reducing support surface F. Oral supplements should be instituted if the patient is found to be undernourished.

The NAP is applying a condom catheter to the patient. The patient asks, "What is the purpose of the skin preparation solution?" The NAP correctly responds: A."It is used before condom sheath application as an adhesive to hold the condom catheter on." B. "It is an antiseptic to clean pathogens from the area before applying the condom catheter." C. "The skin preparation solution prevents skin irritation and should be dry before the condom catheter is applied." D. "The skin preparation solution helps the condom catheter to go on more easily, reducing friction, and should still be wet when the sheath is applied."

C. "The skin preparation solution prevents skin irritation and should be dry before the condom catheter is applied."

If a patient's indwelling catheter is removed at 0900, the patient should be due to void by: A.1900 to 2100 (7:00 PM to 9:00 PM) B. 1100 to 1200 (11:00 AM to 12:00 PM) C. 1500 to 1700 (3:00 PM to 5:00 PM) D. 0930 (9:30 AM)

C. 1500 to 1700 (3:00 PM to 5:00 PM) The patient should be due to void in 6 to 8 hours, or by 3:00 to 5:00 PM. If the patient fails to void, nursing measures should be taken (i.e., assess for bladder fullness, provide privacy, assist to normal voiding position, run water). If unsuccessful, the health care provider should be notified

Which of the following is inappropriate to delegate to nursing assistive personnel (NAP)? A. Emptying a closed drainage container. B. Measuring the amount of drainage. C. Assessment of wound drainage. D. Reporting the amount on the patient's intake and output record.

C. Assessment of wound drainage. Assessment of wound drainage and maintenance of drains and the drainage system require the critical thinking and knowledge application unique to a nurse and therefore are inappropriate to delegate to NAP.

The nurse is preparing an in-service on medical asepsis. Which of the following should be included in the presentation? (Select all that apply.) A. Use sterile gloves if anticipating contact with nonintact skin. B. Artificial nails should be no longer than 0.625 cm (1/4 inch). C. If worn, fingernail polish should not be chipped. D. Cough hygiene practices should be followed. E. Gown and gloves are sufficient PPE for a splash risk. F. Always know a patient's susceptibility to infection.

C. If worn, fingernail polish should not be chipped. Correct D. Cough hygiene practices should be followed. Correct F. Always know a patient's susceptibility to infection. Correct

The nurse is observing the NAP perform hand hygiene. Which of the following, if performed by the NAP, requires intervention by the nurse? (Select all that apply.) The NAP: A. Washes her hands before and after removing clean gloves. B. Applies 3 to 5 mL of antimicrobial soap to hands wet with warm water. C. Takes the patient's blood pressure and leaves the room to document. D. Washes hands with plain soap and water when visibly dirty. E. Puts the patient's socks on, then begins to feed the patient. F. Moves the patient's IV pole by the bed and uses hand sanitizer. G. Has an uncovered cut on the back of the nondominant hand.

C. Takes the patient's blood pressure and leaves the room to document. E. Puts the patient's socks on, then begins to feed the patient. G. Has an uncovered cut on the back of the nondominant hand. Hand hygiene should be performed before and after direct contact with patients, such as taking a blood pressure or when moving from a contaminated body site to a clean body site during patient care. Any open areas of the skin should be covered. All other actions are correct.

The nurse is applying sterile gloves. Which series of steps would require correction? A. Perform hand hygiene. Examine glove package to determine if it is dry and intact. Open sterile gloves by carefully separating and peeling open the adhered package edges. Identify right and left glove. B. With thumb and first two fingers of nondominant hand, grasp edge of the cuff of the glove for the dominant hand. Touch only inside surface of the glove and pull the glove over the dominant hand, carefully working the thumb and fingers into the correct spaces. Gently let go of the cuff while preventing it from rolling up the wrist. C. Slide the fingers of the gloved hand underneath the second glove's cuff. D. Pull the glove over the fingers of the nondominant hand. Avoid touching exposed areas with the gloved hands. D. Hold gloved hands at sides of body, below waist level, until beginning the sterile procedure.

D. Hold gloved hands at sides of body, below waist level, until beginning the sterile procedure. Fingers of the gloved hands should be interlocked and held away from the body, above waist level, until beginning the procedure. Hand hygiene should be performed before applying gloves. The glove package should be examined because a torn or wet package is contaminated. The package is opened by separating and peeling the adhered package edges. With thumb and first two fingers of nondominant hand, grasp edge of the cuff of the glove for the dominant hand. Touch only the inside surface of the glove and pull the glove over the dominant hand, carefully working the thumb and fingers into the correct spaces. Gently let go of the cuff while preventing it from rolling up the wrist. Slide the fingers of the gloved hand underneath the second glove's cuff. Pull the glove over the fingers of the nondominant hand. Avoid touching exposed areas with the gloved hands.

Which of the following would be inappropriate to delegate to NAP? A.Application of a condom catheter. B. Perineal care. C. Emptying a leg bag and recording on I&O record. D. Indwelling catheter insertion.

D. Indwelling catheter insertion.

The nurse is preparing to set up a sterile field for a patient who is going to have a sterile dressing change. Which of the following assessment measures would be unnecessary at this time? A. The nurse reviews documentation to see what supplies will be needed. B. The nurse asks the patient to rate his pain on a pain scale. C. The nurse asks the patient if he needs to use the bathroom. D. The nurse asks the patient if he has ambulated in the hall today.

D. The nurse asks the patient if he has ambulated in the hall today. Assessing the patient's mobility is unnecessary at this time. The nurse should anticipate the number and variety of supplies needed to avoid having to leave a sterile field to obtain more supplies. Premedication may be required if pain level is sufficiently severe. You should anticipate the patient's needs so that the patient can relax and avoid any unnecessary movement that might disrupt the procedure or the sterile field.

The nurse is caring for a patient who had knee replacement surgery 5 days ago. The patient's knee appears red and is very warm to the touch. The patient requests pain medication. Which of the following would be a correct explanation of what the nurse has assessed? A. These are expected findings for this postoperative period. B. The patient is becoming dependent on pain medication. C. The nurse should observe the patient more closely for wound dehiscence. D. The patient is demonstrating signs of a postoperative wound infection.

D. The patient is demonstrating signs of a postoperative wound infection. The risk for infection is greatest 4 to 5 days postoperative. Symptoms of wound infection include fever, tenderness and pain at the wound site, and an elevated white blood cell count, and the edges of the wound may appear inflamed. If drainage is present, it is odorous and purulent, which causes a yellow, green, or brown color, depending on the causative organism

Surgical asepsis (sterile technique)

Surgical technique and aseptic practices maintain an area that is free from pathogenic organisms

DELEGATION OF WOUND CARE

The skill of pressure injury risk assessment or treatment of a pressure injury cannot be delegated to nursing assistive personnel (NAP). The nurse instructs the NAP to: Frequently change patient's position and specific positions individualized for the patient. Report any redness or break in the patient's skin. Report any abrasion from medical devices. Report any wound drainage that might be on linens or intact skin, indicating the need to change the dressing or to use an alternative dressing. Report any new areas of redness, blistering, or skin irritation.

which instruction would the nurse provide a client needing to collect a clean-catch urine specimen? a. urinate a small amount, stop the flow and then fill half of the specimen cup b. collect a sample of the last urine voided during the night c. if anticipating a delay in delivery, keep the samle in a warm dry area

a. urinate a small amount, stop the flow and then fill half of the specimen cup

Which action should the nurse take to maintain sterility when performing a dressing change? A. put the unopened sterile glove package carefully on the sterile field b. remove the sterile drape from its package by lifting it by the corners c. don the sterile gloves before opening the package containing the field drape d. pour irrigation liquid from a ht of at least 3in. from sterile container.

b. remove the sterile drape from its package by lifting it by the corners

which statement would the nurse use to instruct the female patient about obtaining a urine specimen? a. start urinating in the cup and then finish urinating in the toilet b. if you cant fill up the cup, then leave in on the toilet and use it again when you need to void c. with the enclosed towelettes, wipe your labia from front to back before collecting the specimen. d. when you finish leave the cup on the back of the toilet and the aide will get it when making rounds

c. with the enclosed towelettes, wipe your labia from front to back before collecting the specimen.

which instruction would the nurse give to the client having a residual urine test? a. void right after urinary catheter is removed b. collect a specimen of urine during midstream c. attempt to void when a urinary catheter is in place d. empty the bladder before a urinary catheter is inserted.

d. empty the bladder before a urinary catheter is inserted.