NUR 105
- The nurse determines that the sterile field has been contaminated when which action occurs?
Answer 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.
- A group of nurses are reviewing information about asepsis. Which statement by the group
demonstrates the need for additional review?
Answer "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.
- Which are basic principles of surgical asepsis? Select all that apply.
- Never turn the back on a sterile field.,
Answer
- Only a sterile object can touch another sterile object.,
- Avoid talking, coughing, sneezing, or reaching over a sterile field.,
- Consider the outer 1-inch (2.5 centimeters) edge of a sterile field to be contaminated.
Never walk away from or turn the back on a sterile field. This prevents possible contamination while the field is out of the worker's view. Consider the outer 1-inch (2.5 centimeters) edge of a sterile field to be contaminated. Only a sterile object can touch another sterile object. Unsterile touching sterile means contamination has occurred. Avoid talking, coughing, sneezing, or reaching over a sterile field or object. This helps to prevent contamination by droplets from the nose and the mouth or by particles dropping from the worker's arm. Hold sterile objects above waist level.This will ensure keeping the object within sight and preventing accidental contamination. Use dry, sterile forceps when necessary. Forceps soaked in disinfectant are not considered sterile.
- The nurse prepares the sterile tray for indwelling catheter insertion while 1 / 4
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?
Answer Change into a new pair of sterile gloves.
The client must be prepared prior to preparing the catheter kit. The nurse must wear sterile gloves while preparing the sterile tray, because it involves opening sterile supplies. If the nurse then touches a non-sterile surface, like the client's blankets,
the sterile gloves must be changed prior to continuing the procedure. The nurse does not need to reposition the kit at this time. The nurse is no longer sterile and cannot proceed with cleaning the client with sterile solution. Only the nurse's gloves are contaminated; the nurse does not need to dispose of the kit.
- The nurse 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?
Answer 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.
- 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?
Answer Health care-associated infection
This infection is best described as a health care-associated infection. A health care-associated infection is an infection not present on admission to health care agency and that has been acquired during the course of treatment for other conditions. The other terms listed do not apply to this infection.
- Which includes practices used to render and keep objects and areas free from
microorganisms? 2 / 4
Answer 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 uses soap and water for hand hygiene. Which action demonstrates proper
handwashing?
Answer 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 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?
Answer 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.
- A group of students are demonstrating the skill for hand washing. What would indicate a
need for additional teaching?
Answer The students wash their hands for 15 seconds prior to drying them. 3 / 4
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.
- When washing the hands with soap and water what is an appropriate action for the nurse to
perform?
Answer Keep the hands below the elbows.
The nurse keeps the hands lower than the elbows to allow water to flow toward fingertips.When hand washing, the nurse washes jewelry, usually restricted to only a wedding band, before starting; jewelry can harbor microorganisms and contaminants. Next, the nurse would turn on the water, apply soap to the hands, and rub it in using a circular motion. After thoroughly cleaning the hands, the nurse would then clean under the nails. The nurse does not lean on the sink as this can lead to contamination.
- The nurse is preparing to perform handwashing. Place the following steps in the correct
order. Use all options.
Answer 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.
- The nurse performs hand hygiene using an alcohol-based handrub after exiting a client's
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