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 puts on a face mask.
The nurse holds her hands above her waist.
The nurse turns her back to the sterile field.
The nurse touches the outside of the gown.
The Correct Answer is B
Choice A reason: The nurse puts on a face mask is not an action that demonstrates correct aseptic technique. This is an action that should be done before donning a sterile gown and gloves, not after. The nurse should wear a face mask to prevent contamination of the sterile field from respiratory droplets.
Choice B reason: The nurse holds her hands above her waist is an action that demonstrates correct aseptic technique. This is an action that prevents contamination of the sterile gloves from the non-sterile gown. The nurse should keep her hands above her waist and in front of her body at all times.
Choice C reason: The nurse turns her back to the sterile field is not an action that demonstrates correct aseptic technique. This is an action that causes contamination of the sterile field from the non-sterile back of the gown. The nurse should never turn her back to the sterile field or reach over it.
Choice D reason: The nurse touches the outside of the gown is not an action that demonstrates correct aseptic technique. This is an action that causes contamination of the sterile gloves from the non-sterile outside of the gown. The nurse should only touch the inside of the gown or other sterile items.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: A client who has a displaced femur fracture from a fall is a priority client, but not the highest priority. The nurse should assess the client for signs of bleeding, infection, nerve damage, and compartment syndrome, and provide pain relief and immobilization. However, the client's condition is not as urgent or life-threatening as the other clients.
Choice B reason: A client who is experiencing severe vomiting and diarrhea with tachycardia is a priority client, but not the highest priority. The nurse should assess the client for signs of dehydration, electrolyte imbalance, and shock, and provide fluid and electrolyte replacement and antiemetic medication. However, the client's condition is not as urgent or life-threatening as the other clients.
Choice C reason: A client who is confused and has slurred speech is the highest priority client, as these are signs of a possible stroke, which is a medical emergency. The nurse should assess the client for other signs of stroke, such as facial drooping, arm weakness, and vision problems, and initiate the stroke protocol, which includes calling for help, obtaining a CT scan, and administering thrombolytic therapy if indicated.
Choice D reason: A client who has chemical burns covering 20% of the total body surface area is a priority client, but not the highest priority. The nurse should assess the client for signs of airway injury, infection, and fluid loss, and provide wound care, pain relief, and fluid resuscitation. However, the client's condition is not as urgent or life-threatening as the other clients.
Correct Answer is C
Explanation
Choice A reason: Calling the provider if you note clubbing of the client's fingernails is not an instruction the charge nurse should include in the teaching. This is an unnecessary and inappropriate action, as clubbing is a chronic and irreversible sign of hypoxia that does not require immediate intervention. The nurse should document the finding and monitor the client's respiratory status.
Choice B reason: Having an assistive personnel ambulate the client just before meals is not an instruction the charge nurse should include in the teaching. This is a harmful and contraindicated action, as ambulation can increase the client's oxygen demand and cause dyspnea and fatigue. The nurse should schedule the client's activity and rest periods around the meals and provide supplemental oxygen as prescribed.
Choice C reason: Notifying the charge nurse if you observe that the client has distended neck veins is an instruction the charge nurse should include in the teaching. This is a necessary and appropriate action, as distended neck veins can indicate right-sided heart failure, which is a complication of COPD. The nurse should report the finding and assess the client for other signs of fluid overload, such as edema, weight gain, and crackles.
Choice D reason: Maintaining the client's oxygen saturation level above 95 percent is not an instruction the charge nurse should include in the teaching. This is an unrealistic and potentially harmful goal, as clients with COPD usually have lower oxygen saturation levels due to chronic hypoxia. The nurse should maintain the client's oxygen saturation level at the prescribed range, which is typically between 88 and 92 percent.
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