While performing sterile wound care, the nurse accidentally brushes a sterile glove against the client's gown. What is the nurse's next action?

Continue the procedure; the gown is considered clean

Ask another nurse to finish the wound care

Apply extra antiseptic to the glove before touching the wound

Change the contaminated glove immediately

Answer and Explanation

The Correct Answer is D

A. Continue the procedure; the gown is considered clean: Once a sterile glove contacts a nonsterile surface (like a gown), the glove is considered contaminated and the sterile field is compromised.

B. Ask another nurse to finish the wound care: Having another nurse complete care is unnecessary if the glove can be changed immediately; the priority is to restore sterility.

C. Apply extra antiseptic to the glove before touching the wound: Antiseptic on the glove does not restore sterility; contaminated gloves must be replaced rather than "disinfected" in place.

D. Change the contaminated glove immediately: Replacing the contaminated glove right away restores a sterile barrier and prevents introducing microorganisms into the wound.

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Correct Answer is C

Explanation

A. Avulsion: Avulsion involves forcible tearing away of tissue, often with a flap or loss of tissue; it may be extensive but implies more tissue loss rather than just jagged edges.

B. Incision: An incision is a clean, straight surgical cut with tidy edges, not torn or irregular.

C. Laceration: A laceration is characterized by torn, irregular wound edges and separation of tissue, matching this description.

D. Ulceration: An ulcer is a crater-like lesion from tissue breakdown (pressure, ischemia, necrosis), not primarily described as torn, irregular edges from trauma.

A. Leave the room and notify the nursing supervisor B. Treat the evisceration by covering area with sterile gauze pad soaked with sterile saline C. Notify the patient's family D. Instruct her to cough and deep breathe

Correct Answer is B

Explanation

A. Leave the room and notify the nursing supervisor: Leaving the patient delays immediate wound protection and would abandon a patient with an acute surgical emergency; the priority is to protect exposed viscera and get help.

B. Treat the evisceration by covering area with sterile gauze pad soaked with sterile saline: Covering the exposed bowel with sterile, saline-moistened dressings reduces contamination, prevents tissue drying, and is the immediate priority while calling the surgeon/rapid response and keeping the patient NPO and supine.

C. Notify the patient's family: Informing family is important later, but it is not the immediate clinical action; stabilize and protect the patient first.

D. Instruct her to cough and deep breathe: Coughing increases intra-abdominal pressure and can worsen evisceration - this should be avoided.

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While performing sterile wound care, the nurse accidentally brushes a sterile glove against the client's gown. What is the nurse's next action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Explanation

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