The nurse is observing a student nurse complete a urinary catheter insertion. What finding should cause the nurse to pause the procedure and obtain sterile equipment?
The student nurse performs hand hygiene before opening the sterile kit.
The student nurse uses their sterile hand to reposition the client's leg.
The student nurse assesses the client for a latex allergy before beginning the procedure.
The student nurse instructs the client not to touch the sterile field during the procedure.
The Correct Answer is B
A. The student nurse performs hand hygiene before opening the sterile kit: Performing hand hygiene is a standard infection prevention measure and is appropriate before handling sterile equipment. It maintains asepsis and does not compromise the sterile field.
B. The student nurse uses their sterile hand to reposition the client's leg: Touching the client with a sterile hand contaminates it and breaches the sterile field. Any contact with nonsterile surfaces requires the sterile hand to be re-gloved and sterile equipment to be replaced to maintain asepsis.
C. The student nurse assesses the client for a latex allergy before beginning the procedure: Screening for latex allergy is appropriate and prevents allergic reactions. This step does not compromise sterility and is a proper safety measure.
D. The student nurse instructs the client not to touch the sterile field during the procedure: Educating the client to avoid the sterile field helps maintain asepsis and is a correct infection control practice. It does not necessitate halting the procedure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. All visitors should wear hair and shoe covers: Hair and shoe covers are not part of standard contact precautions for MRSA. Transmission occurs primarily through direct contact with contaminated surfaces or wounds rather than hair or footwear. Routine use of these items does not reduce MRSA spread.
B. All visitors should wear a gown and gloves: MRSA requires contact precautions to prevent transmission via hands and clothing. Gowns protect clothing from contamination, and gloves reduce direct contact with infectious material. This practice is consistent with infection prevention guidelines for multidrug-resistant organisms.
C. All visitors should wear goggles and gloves: Eye protection is reserved for situations with a risk of splashing or spraying of body fluids. MRSA wound care does not typically pose this risk during routine contact. Goggles are not routinely indicated.
D. All visitors should wear an N95 mask and gown: N95 respirators are used for airborne pathogens such as tuberculosis, not contact-spread organisms like MRSA. Respiratory protection is unnecessary unless aerosol-generating procedures are involved.
Correct Answer is D
Explanation
A. Reuse the N95 respirator for multiple clients on airborne precautions: N95 respirators are generally single-use devices unless specific crisis reuse protocols are in place. Reusing without proper guidelines increases the risk of contamination and infection transmission. Standard practice is to don a new respirator for each client encounter.
B. Place the N95 respirator in a biohazard bag after use for disposal: N95 respirators should be discarded in regular trash after doffing unless contaminated with bodily fluids. Placing it in a biohazard bag is unnecessary for routine airborne precautions and does not align with standard infection control procedures.
C. Remove the N95 respirator first when doffing PPE after leaving the room: The respirator is the last item to be removed during doffing to maintain protection while exposed. Removing it first could allow airborne pathogens to reach the nurse’s respiratory tract. Proper sequence is essential for safety.
D. Apply the N95 respirator before entering the room and providing care: N95 respirators must be donned prior to entering the room of a client on airborne precautions to filter airborne particles effectively. This protects the nurse from inhaling infectious aerosols and is a primary component of airborne PPE protocol.
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