The nurse is providing care for patients on the medical-surgical unit. Which of the following situations requires the nurse to implement medical asepsis?

Applying sterile gloves to assist with a procedure.

Inserting an indwelling urinary catheter.

Preparing injectable medications.

Picking up soiled tissues off of the bedside table.

Answer and Explanation

The Correct Answer is D

A. Applying sterile gloves to assist with a procedure: This is part of surgical asepsis (sterile technique) rather than medical asepsis.
B. Inserting an indwelling urinary catheter: This requires sterile technique, not just medical asepsis.
C. Preparing injectable medications: Medication preparation requires aseptic (sterile) technique to prevent contamination.
D. Picking up soiled tissues off of the bedside table: Medical asepsis includes hand hygiene and proper handling of contaminated items to prevent the spread of infection.

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Correct Answer is D

Explanation

A. Elbows and behind the ears: These areas are not primary pressure points in a seated position.

B. Coccyx and back of the skull: The coccyx is a pressure point when lying down, but this patient is sitting most of the time.

C. Heels and trochanter: Heels are at risk in supine patients, but this patient is primarily sitting.

D. Sacrum and ischium: The sacrum and ischium (sit bones) bear the most pressure in a seated position, making them highly vulnerable to skin breakdown.

A. Apply restraints to the patient's wrists. B. Turn on the patient's bed alarm. C. Administer a sedating medication. D. Move the patient closer to the nurse's station.

Correct Answer is D

Explanation

A. Apply restraints to the patient's wrists. Restraints should be a last resort and only used when all other interventions have failed. Before restraining, less restrictive methods such as reorientation, supervision, and environmental modifications should be attempted first.

B. Turn on the patient’s bed alarm. While a bed alarm can alert staff if the patient attempts to get out of bed, it does not prevent the patient from pulling at their dressings and IV lines. More direct supervision is needed.

C. Administer a sedating medication. Sedation should be used cautiously, as it may increase the risk of falls, delirium, and respiratory depression. Non-pharmacologic interventions should be attempted first unless the patient is a danger to themselves or others.

D. Move the patient closer to the nurse’s station. This is the best first intervention. Placing the patient closer to the nurses' station allows for increased supervision and quicker intervention while also helping to reduce agitation through reassurance and reorientation.

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The nurse is providing care for patients on the medical-surgical unit. Which of the following situations requires the nurse to implement medical asepsis?

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Correct Answer is D

Explanation

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Explanation

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