Surgical Asepsis
Disinfection 15. Differentiate between disinfection and sterilization.
Disinfection is a process that results in the destruction of most pathogens, but not necessarily their spores. Common methods of disinfection include the use of alcohol wipes or chlorhexidine gluconate (Hibiclens) soap scrub, or a povidone-iodine (Betadine) scrub, to kill microorganisms on the skin. A surgical hand scrub takes longer than regular handwashing and is considered to be a disinfection process. The skin is considered to be disinfected, rather than just clean. Stronger disinfectants include phenol and chlorine bleach, which are generally too strong to be used on living tissue. They are used on surfaces, such as floors and countertops. Boiling also can be used to disinfect inanimate objects; however, it does not destroy all organisms and does not destroy spores. Boiling does not make objects sterile.
Disinfection and Sterilization-what is the difference? 15. Differentiate between disinfection and sterilization.
Disinfection is the process that results in the destruction of most pathogens, but not necessarily their spores. Sterilization is the process of exposing articles to steam heat under pressure or to chemical disinfectants long enough to kill all organisms and their spores.
How do you prevent the spread of microorganisms?
Examples of Client and Family Teaching • Emptying the catheter drainage bag • Safely changing catheter tubing (usually, not the catheter itself) • Hanging a new IV bag • Giving an injection Additional Tips for Teaching • Demonstrate the skill to be performed. • Ask the client and family to repeat the demonstration. • Explain how to recognize problems or complications, such as postoperative infections. • Describe when to seek medical care immediately. • Give the client/family printed instructions, to reinforce teaching. • State where to obtain needed supplies. • If indicated, make a referral for home care nursing follow-up.
7. A 30-year-old client is catheterized after major abdominal surgery. For which reason is the drainage bag placed in a position lower than that of the client's urinary bladder after catheterization? * 1/1
For proper drainage of urine For general comfort of the client For proper positioning of the drainage tube For preventing any type of infection For proper drainage of urine
What happens if a sterile item becomes contaminated? 14. Differentiate between medical and surgical asepsis.
If a sterile item becomes contaminated or if there is uncertainty whether or not it is contaminated, it is considered contaminated and must be discarded.
What should be reported right away after catheter insertion 18. List steps to insert and remove a catheter for male and female clients.
If the client continues to feel a very strong urge to void or severe discomfort after catheter insertion, report this to the provider.
Explain Hair covering
In sterile environments (especially the OR) workers must completely cover the hair. If the hair is long, a hood is worn; if the hair is short, a surgical cap is used. The nurse with a moustache or beard wears a full-face surgical hood, to cover the entire face, except the eyes.
Explain sterile gown 17. Describe steps to open sterile supplies.
In-service education is required before wearing a sterile gown. A sterile gown is commonly worn by scrub personnel in the OR, in protective isolation, and sometimes in the delivery room. When putting on the sterile gown, the hands touch only the parts of the gown that will touch the body after it is in place (only the inside). Another person must tie the strings. The back of the gown and any part of the gown below waist level or above nipple level is considered contaminated, even though it was sterile when put on. When wearing a sterile gown, be careful not to touch anything that is not sterile.
Why is it important to check for patency in a foley catheter and how is that performed? 18. List steps to insert and remove a catheter for male and female clients.
It is important to assure the balloon inflates, and to assure that the right size has been selected. It is also important to assure that sterile technique is performed. Making sure that the urine is flowing out of the urinary meatus is also important??? Before performing any catheterization, make sure the client is not allergic to latex (rubber). Although catheters today usually are not latex, the client with a latex allergy could also have a severe reaction to another type of catheter, even though a special nonallergenic catheter (e.g., polyurethane, Teflon, silicone) is used. If the client's allergy is severe, specific allergy testing must precede catheterization.
Can you sterilize the skin
It is possible to disinfect the skin, but you cannot sterilize the skin
Explain surgical mask and eye protection
Masks are used in the OR, in protective isolation, and in certain other types of client isolation The mask covers the mouth and nose. Its purpose is to provide a barrier against pathogens. In the OR or during sterile procedures, the mask prevents harmful microorganisms in your respiratory tract from spreading to the client. When the client has an infection, the mask protects you from his or her pathogens.
What is asepsis 14. Differentiate between medical and surgical asepsis.
Mechanical cleansing of inanimate objects and hand washing are sufficient to provide medical asepsis.
Explain, Medical and Surgical Asepsis 14. Differentiate between medical and surgical asepsis.
Medical asepsis is clean technique. Surgical asepsis is sterile technique
8. A nurse is preparing to assist the surgeon in a major operation. What are the guidelines taken into consideration to maintain sterility? Select all that apply *
Only clean equipment should be used for any surgical procedure Reaching over a sterile field should be avoided, unless sterile clothing is worn The mask must be changed for a new sterile mask if it becomes wet Sterile packages should be placed on a clean working area When the nurse is pouring a sterile solution, the inside of the bottle should not be touched Reaching over a sterile field should be avoided, unless sterile clothing is worn The mask must be changed for a new sterile mask if it becomes wet When the nurse is pouring a sterile solution, the inside of the bottle should not be touched
How do you take off gloves? 17. Describe steps to open sterile supplies.
Safe removal of gloves. A. Touch only the outside of the contaminated glove (inside a folded-down cuff) with gloved fingers. B. Touch the skin only with bare fingers. Roll gloves together, with contaminated areas inside the roll and discard appropriately. Wash hands carefully.
6. In the operating room, a nurse touches she stings of the sterile gown worn by another nurse with a sterile gloved hand, What is the next step to be taken by the nurse? *
Soak the gloved hand in warm saline water Wash the gloved hands with a povidone-iodine scrub Discard the gloves and use a fresh pair Continue wearing the gloves, because the gown was sterile Discard the gloves and use a fresh pair
Define sterile 14. Differentiate between medical and surgical asepsis.
Sterile identifies an item that is free of all microorganisms and spores.
10. A 30-year-old client has received multiple wounds on her arm and face in a motor vehicle accident. The nurse uses betadine to clean the wounds. What term best describes this process? *
Sterilization Disinfection Mechanical cleansing Surgical asepsis Disinfection
surgical asepsis or sterile technique 15. Differentiate between disinfection and sterilization.
Surgical asepsis uses sterile technique for all procedures. Use of effective sterile technique means that no organisms are carried to the client. All microorganisms and spores are destroyed before they can enter the body.
Explain the balloon on the catheter? 18. List steps to insert and remove a catheter for male and female clients.
The balloon is deflated when removing a retention catheter. The catheter is never cut for removal.
Why does the drainage bag need to be lower than the client? 18. List steps to insert and remove a catheter for male and female clients.
The drainage bag must be lower than the client's bladder for the urine to drain properly and to help prevent infection.
Medical Asepsis or Clean Technique 14. Differentiate between medical and surgical asepsis.
The purpose of maintaining medical asepsis is to prevent the spread of disease from one person to another, whether it is from client to nurse, client to client, nurse to client, or from a person to the environment. Remember, handwashing is the most important medical asepsis technique; skin cannot be sterilized, but it can be cleaned.
How is side lying catheterization performed? 18. List steps to insert and remove a catheter for male and female clients.
The side-lying position for female catheterization. Shown here is the position for the left-handed nurse. A. The client is positioned on her side. After the client is positioned, the nurse must put on sterile gloves (because these gloves were contaminated during positioning). B. The urinary (urethral) meatus is exposed and the catheter inserted.
Reasons for sterile techniques 16. List guidelines to follow when using sterile technique.
To prevent the spread of infection, the supplies used for surgical and other sterile procedures must be free of all microorganisms. Anything that either touches an open wound or skin break, enters a sterile body cavity, or punctures the skin must be sterile, to prevent introducing microorganisms any healthcare facilities prepare sterile supplies in a central supply room (CSR), also called central sterile supply (CSS), or purchase them in a sterile package and dispose of them after use. Some items, such as surgical towels or drapes, are packaged, secured with special masking tape, labeled, and sterilized by autoclave Items such as syringes and needles are packaged individually by the manufacturer, sterilized before distribution, and discarded after one use.
Removal of Sterile or Nonsterile Gloves 17. Describe steps to open sterile supplies.
To remove gloves, whether they are sterile or clean, pull one glove down over the other. Place the gloved fingers of your first hand only under the outside cuff of the glove being pulled off The glove that was pulled off is held in the gloved hand. Then, slide the ungloved fingers of the other hand inside the second glove, pulling it off and over the first glove. This time, put your fingers inside the glove and avoid touching the outside of the gloves with your ungloved fingers. Keep the outsides of the gloves inside the rolled-up gloves
What happens when a sterile item touches a nonsterile item? 14. Differentiate between medical and surgical asepsis.
When a sterile item touches anything unsterile, the sterile item becomes contaminated.
Are objects still sterile if they become wet?
Whenever the cover on a sterile tray, or a gown, mask, dressing, drape or other sterile cloth or paper item becomes wet, it is contaminated.
The nurse is assisting with a surgical procedure and hands the surgeon an instrument free of microorganisms and spores to prevent surgical site infection. The nurse is ensuring that this is which category of instrument?
a. Clean b. Sterile c. Contaminated d. Disinfected
The nurse accidently touches a sterile instrument with a nonsterile object. What is the most appropriate action for the nurse to take?
a. Discard the instrument in the trash. b. Wash the instrument with soap and water and reuse. c. Obtain another sterile instrument to use. d. Use the instrument since it has limited exposure to the unsterile object.
The nurse is setting up a sterile field for a client's surgical procedure and spills sterile water on the sterile wrapper
a. Obtain another surgical instrument tray because it is contaminated. b. Cut the wet area away with sterile scissors. c. Use the tray because the saline was sterile. d. Remove the wrapping and use the tray.
A client is being discharged from the acute care facility after successful treatment for pneumonia. An incentive spirometer is left behind. What is the appropriate nursing action?
a. Soak the incentive spirometer in a chemical disinfecting solution for reuse. b. Have the incentive spirometer sterilized for reuse. c. Discard the incentive spirometer. d. Clean the incentive spirometer with alcohol wipes and reuse.
13. List five examples of sterile and non-sterile body areas.
he skin, mouth, gastrointestinal tract, and upper respiratory tract. These areas are open to the outside and are inhabited by microorganisms at all times the abdominal cavity or the ovary) or they do not normally contain microorganisms. Some areas (e.g., the urinary bladder) are susceptible to infection. (The bladder is normally considered to be sterile, even though it is open to the outside.)
Describe Surgical Asepsis or Sterile Technique 14. Differentiate between medical and surgical asepsis.
is used. Surgical asepsis uses sterile technique for all procedures. Use of effective sterile technique means that no organisms are carried to the client. All microorganisms and spores are destroyed before they can enter the body
List steps to remove a catheter for male and female clients
look in chapter 57 and practice
What do you do before performing any catheterization?
make sure the client is not allergic to latex (rubber). Although catheters today usually are not latex, the client with a latex allergy could also have a severe reaction to another type of catheter, even though a special nonallergenic catheter (e.g., polyurethane, Teflon, silicone) is used. If the client's allergy is severe, specific allergy testing must precede catheterization.
What is a safe amount of urine to be removed from the bladder at one time?
no more than 750 to 1,000 mL of urine can be safely removed from the bladder at any one time, particularly if the client has had urine retention or abdominal distention for some time
Explain sterile gloves 17. Describe steps to open sterile supplies.
practice is required in order to put on sterile gloves without contaminating the gloves or anything else in the sterile area. Remember that once gloves are put on, touching anything nonsterile contaminates them. Therefore, make all preparations before putting on sterile gloves. In Practice: Nursing Procedure 57-2 describes a method of gloving called open gloving.
What are the rules about wearing a mask?
the mask is contaminated, because it touches the nurse's face. Do not touch the mask with sterile gloves. If the mask becomes wet, it must be changed, because it is no longer effective.
Urinary Catheterization-DESCRIBE PROPER TECHNIQUE AND PURPOSE FOR EACH OF THE FOLLOWING Caring for the Client After Catheterization 18. List steps to insert and remove a catheter for male and female clients.
· After catheterization, reposition the client to ensure that he or she is comfortable and the signal cord is within reach. · Be sure the balloon of an indwelling catheter is inflated and the catheter tubing is secured externally, to avoid pulling and discomfort. · Use hypoallergenic tape to hold the catheter to the man's abdomen or thigh or the women's thigh. · Explain to the client that he or she may feel the urge to void, because of the catheter's presence in the urethra, particularly within the first 30 minutes of insertion. · This feeling should diminish and usually goes away within an hour.
Urinary Catheterization-DESCRIBE PROPER TECHNIQUE AND PURPOSE FOR EACH OF THE FOLLOWING Catheterizing the Male Client 18. List steps to insert and remove a catheter for male and female clients.
· Catheterization of the male offers challenges, because the male urethra is longer and more curved and the man may have an enlarged prostate constricting or obstructing the urethra. · Previous urethral infection cal also cause stricture.
Urinary Catheterization-DESCRIBE PROPER TECHNIQUE AND PURPOSE FOR EACH OF THE FOLLOWING The Side-Lying Position 18. List steps to insert and remove a catheter for male and female clients.
· If the female client is unable to lie on her back for catheterization, or cannot relax her legs because of contractures, use the side-lying position. · This position facilitates accurate sterile technique, because the nurse needs to hold only one side of the labia in position. · Contamination of the catheter is less likely because this position is easier for the client to maintain,and the nurse does not need to reach over the client's leg.
Urinary Catheterization-DESCRIBE PROPER TECHNIQUE AND PURPOSE FOR EACH OF THE FOLLOWING Catheterizing the Female Client 18. List steps to insert and remove a catheter for male and female clients.
· May be necessary when women have pelvic surgery or bladder tumor. · In some cases, a suprapubic catheter is inserted during surgery.
Urinary Catheterization-DESCRIBE PROPER TECHNIQUE AND PURPOSE FOR EACH OF THE FOLLOWING Self Catheterization 18. List steps to insert and remove a catheter for male and female clients.
· May be necessary when women have pelvic surgery or bladder tumor. · In some cases, a suprapubic catheter is inserted during surgery.
Urinary Catheterization-DESCRIBE PROPER TECHNIQUE AND PURPOSE FOR EACH OF THE FOLLOWING Removing Retention Catheters 18. List steps to insert and remove a catheter for male and female clients.
· The balloon is deflated and the catheter is gently pulled out, preventing urethral trauma.
What is an autoclave
(18 lb pressure, at a temperature of 125°C [257°F], for 15 minutes) will kill even the toughest organisms and spores.
18. List steps to insert and catheter for female clients.
1. Adjust the bed to a comfortable working height. If right-handed, stand on the client's right side (if left-handed, stand on the client's left side). 2. Determine if the client is allergic to any antiseptic, such as Betadine, or to latex. 3. Assist the client into a supine position with her feet spread apart and flat on the mattress and her knees flexed. Use a bath blanket to drape the client. 4. Put on clean gloves. Wash the client's perineal area with soap and water, rinse, and dry. Remove gloves and wash your hands. 5. Ensure adequate lighting. Position a lamp at the foot of the bed, or another nurse may hold a flashlight. Place an opened biohazard bag within reach. It is often handy to tape it to the overbed table. 6. Raise the bedside table to waist height. Open the sterile catheterization tray on the bedside table using appropriate sterile technique (see In Practice: Nursing Procedure 57-1). Put on sterile gloves (see In Practice: Nursing Procedure 57-2). Grasp the sterile drape and gently allow the drape to unfold. Grasp the upper corners and fold the drape back over your hands (which are within the sterile gloves), making a cuff with the drape. Keep the hands inside this cuff. Ask the client to lift her buttocks. Place the drape between her thighs with the upper edge under her buttocks. If desired, place the fenestrated drape over the perineal area so only the labia are exposed. Do not touch the client's skin with the sterile gloved hands 7. Set up equipment on the open sterile tray: a. Place the cotton balls into the cup or into the receptacle of the molded tray. Open the package containing antiseptic (usually Betadine) and pour it over the cotton balls. b. Remove the plastic covering from the catheter. For an indwelling catheter, attach the prefilled syringe to the balloon inflation port and inflate the balloon with the appropriate amount of fluid to test the balloon. (Usually 5 or 30 mL.) After the balloon inflates, aspirate the fluid back into the syringe, leaving the syringe connected to the port and the balloon deflated. c. Open the lubricant and lubricate the catheter's tip 1 to 2 in. (You may leave the catheter tip inside the sterile lubricant package until you need it.) d. Unscrew the cap from the specimen container, if a specimen is ordered. e. If a straight catheter is being used, position the drainage end of the catheter in the basin to catch the urine. Rationale: Correct preparation ensures that all equipment is present. Inflating the catheter balloon before use checks for leaks or a nonfunctioning balloon. Lubrication of the catheter increases comfort on insertion. 8. Move the catheterization tray with the equipment onto the sterile drape between the client's thighs. If performing a straight catheterization, move the collection basin close to the perineum. 9. Before proceeding, make sure you have all supplies and equipment and are ready to contaminate the nondominant hand. Using the nondominant hand, separate and gently spread the woman's labia minora to expose the urinary meatus. Keep this hand in position; do not move it once you have touched the client. 10. With the dominant hand, use the forceps to pick up cotton balls that have been soaked with the antiseptic solution (Betadine). Use cotton balls to cleanse, as follows: labial fold on the side farthest from you; labial fold on the near side; and urinary meatus. Use a new cotton ball for each stroke, moving from top to bottom (front to back). Discard each used cotton ball in the biohazard bag. Never cross a sterile field with used cotton balls or any other contaminated item—move your hand around the sterile field. 11. Pick up the catheter approximately 3 in from the tip with the dominant hand. Make sure the drainage end of the straight catheter is in the basin to catch the urine flow. (If a specimen is ordered, place the drainage end into the specimen container.) If the catheter is indwelling, it is usually attached to the drainage tubing and collection bag. 12. Locate the urinary meatus on the perineum. Ask the client to breathe deeply and slowly through the mouth. Insert the catheter gently into the urinary meatus, advancing it 2 to 3 in until urine begins to drain. If the catheter is indwelling, advance it another 1 to 2 in. Never force insertion of the catheter if resistance is felt. Do not let go of the catheter during this insertion and do not withdraw it. When the catheter is in place, move the nondominant hand to hold it in place between two fingers, bracing the rest of this hand against the client's perineum. Collect a urine specimen if one is ordered. 13. If the catheter is not to be indwelling, allow urine to drain into the basin. Remove the catheter after urine has drained. (Remember to check beforehand to determine the maximum amount of urine to be drained at one time.) For an indwelling catheter, inject sterile water (or normal saline) to inflate the balloon. Pull very gently on the catheter to check that the balloon is inflated and the catheter is secure. ("Seating the balloon.") Then, push back on the catheter a fraction of an inch. 14. Use tape to anchor the tubing from the indwelling catheter onto the client's thigh. Position the drainage bag below bladder level. The catheter should pass over the client's leg. Allow some slack in the catheter tubing. 15. Clean the Betadine off the client's perineum and dry the area. Measure the urine amount. See Chapter 51 for catheter care. Rationale: These measures ensure comfort, safety, and accuracy. Follow ENDDD Steps
What are the steps for sterile technique 16. List guidelines to follow when using sterile technique.
1. After sterile gloves (and/or gown) have been put on, the nurse cannot touch anything that is not sterile. Keep hands between nipple and waist level, whether or not a gown is worn. 2• Reaching over a sterile field contaminates the sterile area, unless sterile clothing and gloves are being worn. 3. If a sterile wrapper becomes wet, the wrapper and its contents are no longer sterile. 4• If a mask becomes wet, it no longer screens out microorganisms; the mask must be changed for a new mask. 5• When wearing sterile gloves to perform a sterile procedure, keep them in front, between the nipple line and waist. If gloves move above or below these areas, they are considered contaminated. 6 • A person's back is not sterile, even if a sterile gown is being worn. 7• Objects are considered contaminated if there is any uncertainty whether contamination has occurred. When in doubt, consider the objects in question to be contaminated. 8• Skin cannot be rendered sterile; it can only be made clean. 9• Parts of the body that are not normally exposed to the outside are considered sterile. These parts include the abdominal cavity, the urinary bladder, and usually the uterus.
17. Describe steps to open sterile supplies.
1. Check the expiration date on sterile supplies. Prepare a waist-high working area 2. Place the sterile package on the working area. Remove the outer covering or plastic wrap if present 3. Grasp the edge of the outermost flap of the inner wrapper and open the package away from you, toward the back of the table. 4. Using your left hand, fold the flap on the left side down toward the table. Using your right hand, repeat with the right side flap. Then, after opening both side flaps, push up on the underside of the wrapper, to bend it up in the middle and pull the near flap out flat, grasping only its tip. Do not touch any part of the sterile field. Pull the flaps taut and flat onto the table. 5 Opening left side flap away from the center. 6. Opening right side flap. 7. Dropping sterile contents on the sterile field, keeping at least 2 in from the edge of the sterile drape. 8. Open any additional sterile packages without touching the contents. Drop these items onto the sterile field, staying at least 2 in from the edges. Do not allow the wrappings from these packages to touch the sterile field; dispose of the wrappers appropriately. Do not reach over the sterile field more than absolutely necessary. Do not touch the sterile drape with your body or clothing. 9. Opening bottom flap toward the nurse's body and folding it backward, to prevent it from re-entering the sterile field. 10. Pour any sterile solutions into basins or cups, as instructed. Hold the bottle with the label upward. Do not touch the inside of the bottle, its cap, or the basin into which the solution is poured. Place the cap, with inside up, on a nonsterile area. If the bottle has been previously opened, "lip" it by pouring a small amount off first, into a sink or lined trash receptacle, before pouring onto the sterile field. Pour solution slowly into the basin or cup, to prevent splashing solution. Do not touch the sterile drape with your body or clothing 11. Pouring sterile solution into sterile cup without touching the sterile field and without splashing.
Donning sterile gloves 17. Describe steps to open sterile supplies.
1. Open the outer glove package, on a clean, dry, flat surface at waist level or higher. 2. If there is an inner package, open it in the same way, keeping the sterile gloves on the inside surface with cuffs toward you. 3. Use the nondominant hand to grasp the glove for the dominant hand, touching only the inside upper surface of the glove's cuff. Lift the glove up and clear of the wrapper. Avoid touching the outside of this glove with either hand. 4. Insert the dominant hand into the glove, placing the thumb and fingers in the proper openings. Pull the glove into place, touching only the inside of the glove at the cuff with your ungloved hand. Leave the cuff in place. 5. To put on the second glove, insert the fingers of the sterile gloved hand between the cuff and the glove (on the outside of the glove). Be sure to touch only the outside of the second glove with sterile gloved fingers. Keep the sterile gloved thumb pointed outward. Lift the glove up and clear of the wrapper. 6. a. Insert the ungloved hand into the glove. b. Pull the second glove on, touching only the outside of the sterile glove with the other sterile gloved hand and keeping the fingers of the first hand between the cuff and the sterile glove. c. Adjust gloves and snap cuffs into place. Avoid touching the inside glove and wrist areas with the sterile gloves. 7. Keep the sterile gloved hands between waist and nipple level. Make sure not to touch the clothes or anything that is unsterile. Keep hands folded when not performing a procedure.
16. List guidelines to follow when using sterile technique.
1.After sterile gloves (and/or gown) have been put on, the nurse cannot touch anything that is not sterile. Keep hands between nipple and waist level, whether or not a gown is worn. 2• Reaching over a sterile field contaminates the sterile area, unless sterile clothing and gloves are being worn. 3• If a sterile wrapper becomes wet, the wrapper and its contents are no longer sterile. 4• If a mask becomes wet, it no longer screens out microorganisms; the mask must be changed for a new mask. 5 • When wearing sterile gloves to perform a sterile procedure, keep them in front, between the nipple line and waist. If gloves move above or below these areas, they are considered contaminated. 6• A person's back is not sterile, even if a sterile gown is being worn. 7 • Objects are considered contaminated if there is any uncertainty whether contamination has occurred. When in doubt, consider the objects in question to be contaminated. 8• Skin cannot be rendered sterile; it can only be made clean. 9• Parts of the body that are not normally exposed to the outside are considered sterile. These parts include the abdominal cavity, the urinary bladder, and usually the uterus. Hair Covering In sterile environments (especially the OR) workers must completely cover the hair. If the hair is long, a hood is worn; if the hair is short, a surgical cap is used. The nurse with a moustache or beard wears a full-face surgical hood
List steps to insert and catheter for male clients.
57-4 procedure in book and practice
What is the difference between catheterization with a Coud'-tip catheter versus a foley catheter?
A Coudé-tip catheter is a special catheter used with a male who has prostate enlargement or the female who has abnormal placement of the urinary meatus. A Foley catheter is a simple indwelling urinary catheter.
Is a catheter ever cut for removal? Explain 18. List steps to insert and remove a catheter for male and female clients.
A catheter is never cut for removal. This could cause the catheter to be pulled back into the urethra or bladder. In that case, surgical removal would probably be necessary. This would also be a prime source for introducing pathogenic organisms into the urinary bladder.
Can a client go into shock if too much urine is removed, explain?
A client can go into shock if too much urine is removed too quickly. Check the facility policy before performing catheterization, to determine the maximum amount of urine to be removed at one time.
The nurse is disinfecting a client's skin prior to a surgical procedure. What method would be most effective? Select all that apply.
A. Chlorhexidine gluconate scrub b. Povidone-iodine scrub c. Soap and water scrub d. Hydrogen peroxide scrub ab
What is the best agent for disinfecting? 15. Differentiate between disinfection and sterilization.
Alcohol wipes or chlorhexadine gluconate Soap scrub or betadine scrub for skin Inanimate objects is boiling water Floors and counters chlorine bleach and phenol
Purpose for surgical Asepsis or sterile technique 14. Differentiate between medical and surgical asepsis.
All microorganisms and spores are destroyed before they can enter the body. In some cases, sterile and clean techniques are combined. For example, for many dressing changes or for procedures such as tracheostomy care or emptying a catheter drainage bag, sterile materials are used, but clean gloves are worn.
What is surgical Asepsis 14. Differentiate between medical and surgical asepsis.
An item or area is free of ALL microorganisms and spores.
4. A nurse has to clean the inanimate objects in the blood collection room. Which should the nurse use for the mechanical cleansing of inanimate objects? *
Antiseptic cleanser Hexachlorophene Betadine Ethylene oxide Hexachlorophene
5. A nurse is preparing to assist the healthcare provider in performing a lumbar puncture, which is a sterile procedure. The nurse has put on sterile gloves and a sterile gown. Where on the surgical gown can the nurse safely place his gloved hands while waiting for the healthcare provider to be ready? * 1/1
Between the neck and the nipples Between the nipples and the waist Between the waist and the hips Between hips and the knees Between the nipples and the waist
What procedures require sterile technique 16. List guidelines to follow when using sterile technique.
Care of the indwelling catheter Surgical intervention and invasive procedures sterile dressing change suture and staple removal administration of parenteral medications venipuncture and management
What is catheterization? 18. List steps to insert and remove a catheter for male and female clients.
Catheterization is the procedure of inserting a flexible tube through the urethra into the bladder to remove urine. This procedure requires sterile equipment and technique.
3. A 35-year-old female client is catheterized after a hysterectomy, and the urine flow seems undiminished after the withdrawal of a normal quantity of urine. What immediate action should the nurse take? *
Check for regularity of the client's pulse rate Check the position of the catheter Remove the catheter and inform the healthcare provider Remove and reinsert the catheter properly. Remove the catheter and inform the healthcare provider
A nurse is required to care for a newborn. Which should be used to disinfect the nurse's hands before handling the baby? *
Chlorine bleach Hexachlorophene Ethylene oxide Distilled water Hexachlorophene
What is important about clean 14. Differentiate between medical and surgical asepsis.
Clean applies to medical asepsis. It denotes removal of gross contamination and many microorganisms.
1. The nurse preparing to inject insulin into a diabetic client. Which technique is appropriate for the process? *
Clean technique Disinfection Medical asepsis Surgical asepsis Surgical asepsis
What is important about client and family teaching/
Client and family teaching is vitally important, especially if the client or family will need to perform sterile procedures, such as IV therapy or catheter care, after discharge.
How do you educate the client after catheter removal 18. List steps to insert and remove a catheter for male and female clients.
Client education encourages cooperation and lessens anxiety. Teach the client to: • Drink plenty of fluids (to facilitate voiding). • Report the urge to void for the first time after catheter removal. • Understand that some discomfort may be felt with the first voiding. • Report any severe pain or blood in the urine.
9. Given below are a few steps for the removal of a retention catheter, What is the correct order for the nurse to remove the retention catheter? A- Gently and slowly pull the catheter out. B- Deflate the balloon by completely aspirating all the fluid C- Ask the client to inhale and exhale slowly and deeply D- Adjust the bed to a comfortable height * 1/1
DCBA DBCA CDBA BDAC DBCA
What is the difference between contaminated and dirty? 15. Differentiate between disinfection and sterilization.
Dirty is a term for any object that has not been cleaned or sterilized to remove microorganisms. Contaminated object is any object that is not sterile. This includes items that are dirty, as well as those that are considered to be only clean.