A nurse is supervising a newly licensed nurse who is performing surgical asepsis. After donning a sterile gown and gloves, which of the following actions by the newly licensed nurse demonstrates correct aseptic technique?

The nurse turns her back to the sterile field.

The nurse holds her hands above her waist.

The nurse applies goggles.

The nurse puts on a face mask.

Answer and Explanation

The Correct Answer is B

A.   Turning one's back to the sterile field is not an appropriate aseptic technique. Doing so risks contaminating the sterile field as the nurse’s back may inadvertently come into contact with sterile items or may cause contamination from the environment.
B.   Holding the hands above the waist is correct aseptic technique. Once sterile gloves are donned, the nurse should keep their hands above the waist and in front of them to maintain sterility. This position helps prevent accidental contamination of the gloves or sterile field and ensures that the hands remain within the sterile zone.
C.   While applying goggles is an important part of personal protective equipment (PPE) in some situations, it is not specifically related to maintaining surgical asepsis after donning a sterile gown and gloves. Goggles may be used for protection against splashes or droplets, but they do not directly impact the sterility of the surgical field or the aseptic technique of handling sterile items.
D.   Putting on a face mask is an essential part of PPE for maintaining sterile technique and protecting both the patient and the nurse from contamination. However, this action typically occurs before donning the sterile gown and gloves.

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Correct Answer is D

Explanation

A. Instructing a client on self-administration of a tap water enema involves providing education and guidance, which is within the scope of the nurse’s role. This task requires assessing the client’s understanding and ability to perform the procedure correctly.
B. Suctioning a client’s long-term tracheostomy involves specialized skills and knowledge, including the ability to manage potential complications and assess the client’s respiratory status. This task should be performed by a registered nurse or a licensed practical nurse who has the necessary training and expertise.
C. Changing the dressing on a PICC line involves sterile technique and specialized knowledge to prevent infection and ensure proper care of the central line. This task should be performed by a registered nurse or a licensed practical nurse with the appropriate training, as it requires assessment skills and adherence to infection control practices.
D. Using a pain rating scale to monitor a client’s pain level is a task that can be safely delegated to assistive personnel. It involves asking the client to rate their pain and recording the response, which is a straightforward task that does not require advanced clinical judgment.

A. Report of photophobia B. Increased temperature C. Decreased level of consciousness D. Generalized rash over trunk

Correct Answer is C

Explanation

A. Photophobia (sensitivity to light) is a common symptom in meningitis due to irritation of the meninges. While it is an important symptom to note and manage, it does not typically represent an immediate life-threatening condition.
B. An increased temperature (fever) is a common finding in meningitis and indicates an inflammatory response. While fever is important to manage, it is not as urgent as changes in consciousness or neurological status.
C. A decreased level of consciousness is a critical finding in a client with meningitis. This can indicate a worsening of the condition, such as increased intracranial pressure, brain herniation, or severe complications. Changes in consciousness are potentially life-threatening and require prompt evaluation and intervention by the healthcare provider to address any emergent issues and prevent further deterioration.
D. A generalized rash could indicate a specific type of meningitis, such as meningococcal meningitis, which can present with a characteristic petechial or purpuric rash. While a rash is a significant finding and should be reported, it is not as immediately critical as changes in consciousness.

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A nurse is supervising a newly licensed nurse who is performing surgical asepsis. After donning a sterile gown and gloves, which of the following actions by the newly licensed nurse demonstrates correct aseptic technique?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a medical-surgical unit is delegating client care. Which of the following tasks should the nurse delegate to an assistive personnel?

Correct Answer is D

Explanation

A nurse is assessing a client who has meningitis. Which of the following findings should the nurse report to the provider immediately?

Correct Answer is C

Explanation

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