Clinical Nursing Skills and Techniques 8th Edition by Anne Griffin Perry - Test Bank

Chapter 4: Documentation and Informatics MULTIPLE CHOICE 1. The patient is a 24-year-old man who is diagnosed with possible HIV infection while being treated for active pneumonia. He has stated that the nurse may share test result information with his significant other but nothing else at this time. With whom may the nurse communicate regarding this information? a. The patient’s parents b. The patient’s significant other only c. No one in the hospital until the patient says so d. The patient’s physician, significant other, and laboratory personnel ANS: D All members of the health care team are legally and ethically obligated to keep patient information confidential. Do not discuss the patient’s examinations, observations, conversations, or treatments with other patients or staff not involved in the patient’s care, unless permission is granted by the patient. DIF: Cognitive Level: Application REF: Text reference: p. 49 OBJ: Describe measures to maintain confidentiality of patient information. TOP: Confidentiality KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 2. Which of the following is the best example of objective charting? a. “The patient states that he has been having severe chest discomfort.” b. “The patient is lying in bed and seems to be in considerable pain.” c. “The patient appears to be pale and diaphoretic and complains of nausea.” d. “The patient’s skin is ashen and respiratory rate is 32 and labored.” ANS: D A record or report contains descriptive, objective information about what you see, hear, feel, and smell. An objective description is the result of direct observation and measurement, such as “respiratory rate 20 and unlabored.” Objective documentation should include your observations of patient behavior. For example, objective signs of pain include increased pulse rate, increased respiration, diaphoresis, and guarding of a body part. The only subjective data included in a record are what the patient actually verbalizes. Write subjective information with quotation marks, using the patient’s exact words whenever possible. For example, you record, “Patient states, ‘my stomach hurts.’” Avoid terms such as appears, seems, and apparently, which are often subject to interpretation. For example, the description “the patient seems to be in pain” does not accurately communicate the facts to another caregiver. The phrase seems is not supported by any objective facts. DIF: Cognitive Level: Analysis REF: Text reference: p. 50 OBJ: List guidelines for effective communication and reporting. TOP: Objective Documentation KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 3. Which of the following is the best example of accurate documentation? a. “Abdominal wound is 5 cm in length without redness, edema, or drainage.” b. “OD to be irrigated qd with NS.” c. “No complaint of abdominal pain this shift.” d. “Patient watching TV entire shift.” ANS: A The use of exact measurements in documentation establishes accuracy. For example, charting that an abdominal wound is “5 cm in length without redness, edema, or drainage” is more descriptive than “large wound healing well.” It is essential to know the institution’s abbreviation list, and to use only accepted abbreviations, symbols, and measures (e.g., metric), so that all documentation is accurate and is in compliance with standards. For example, the abbreviation for every day (qd) is no longer used. If a treatment or medication is needed daily, the nurse should write out the word “daily” or “every day” on the written order or care plan. The abbreviation qd (every day) can be misinterpreted to mean O.D. (right eye). The term “no complaint” may indicate stoicism on the part of the patient. He may have been in excruciating pain but never complained of it. It also creates a question related to the assessment skills of the nurse. It is essential to avoid unnecessary words and irrelevant details. For example, the fact that the patient is watching TV is only necessary to report when this activity is significant to the patient’s status and plan of care. DIF: Cognitive Level: Evaluation REF: Text reference: pp. 51-52 OBJ: List guidelines for effective communication and reporting. TOP: Accurate Documentation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. Patients on the unit have their vital signs taken routinely at 0800, 1200, 1600, and 2000. At 1000, a patient complains of feeling “light-headed.” The nurse takes the patient’s vital signs and finds blood pressure to be lower than usual. Within 15 minutes, the patient says that he feels better. The nurse rechecks the blood pressure and finds that it is now back to normal. How should the nurse handle documentation for this episode? a. Document the 1000 vital signs in the graphic record only. b. Not report the incident because it was a transient episode. c. Document the vital signs in the graphic and progress record. d. Document the vital signs as 12 o’clock signs. ANS: C When documenting a significant change on a flow sheet, you describe the change, including the patient response to nursing interventions, in the progress notes. For example, if a patient’s blood pressure becomes dangerously low, record the blood pressure in the progress notes, as well as relevant assessment such as pallor and dizziness and any interventions performed to raise the blood pressure. Common issues in malpractice caused by inadequate or incorrect documentation include failing to give a report or giving an incomplete report to an oncoming shift and failing to document the correct time of events. DIF: Cognitive Level: Application REF: Text reference: pp. 53-54 OBJ: Identify the purpose of the patient record. TOP: Flow Sheets and Graphic Records KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 5. The nurse manager is attempting to determine the staffing needs of the unit. One tool that she may use to determine the level of care needed would be: a. the standardized care plan. b. the acuity record. c. the patient care summary. d. flow sheets. ANS: B Health care organizations use a patient acuity system as a method of determining the intensity of nursing care required for a group of patients. Acuity measurements for patients on a unit serve as a guide for determining staffing needs. An acuity recording system determines the hours of nursing care and the number of staff required for a nursing unit. Some health care organizations use standardized care plans for more efficient documentation. These plans, based on the institution’s standards of nursing practice, are preprinted, established guidelines used to care for patients with similar health problems. Many health care organizations now have computerized systems that provide concise, summative information in the form of a patient care summary. Flow sheets and graphic records permit concise documentation of nursing information and patient data over time. Records include documentation of routine observations or repeated specific measurements about the patient such as vital signs, intake and output, hygiene, and medication administration. DIF: Cognitive Level: Analysis REF: Text reference: p. 54 OBJ: Identify the purpose of the patient record. TOP: Acuity Records KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 6. A preprinted guideline used to care for patients with similar health problems is known as the: a. acuity record. b. standardized care plan. c. patient care summary. d. flow sheet. ANS: B Some health care organizations use standardized care plans for more efficient documentation. These plans, based on the institution’s standards of nursing practice, are preprinted, established guidelines that are used in caring for patients with similar health problems. Health care organizations use a patient acuity system as a method of determining the intensity of nursing care required for a group of patients. Acuity measurements for patients on a unit serve as a guide for determining staffing needs. Many health care organizations now have computerized systems that provide concise, summative information in the form of a patient care summary. Flow sheets and graphic records permit concise documentation of nursing information and patient data over time. Records include documentation of routine observations or repeated specific measurements about the patient such as vital signs, intake and output, hygiene, and medication administration. DIF: Cognitive Level: Analysis REF: Text reference: p. 54 OBJ: Identify the purpose of the patient record. TOP: Standardized Care Plans KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 7. The patient is ready to go home from the hospital. What does the nurse provide to the patient and his family before he leaves the facility? a. Discharge summary b. Standardized care plan c. Patient care summary d. Flow sheet ANS: A When a patient is discharged from a health care institution, the members of the health care team prepare a discharge summary. A discharge summary provides important information related to the patient’s ongoing health problems and need for health care after discharge. You enhance discharge planning when you are responsive to changes in patient condition and involve the patient and family in the planning process. Some health care organizations use standardized care plans for more efficient documentation. These plans, based on the institution’s standards of nursing practice, are preprinted, established guidelines used to care for patients with similar health problems. Many health care organizations now have computerized systems that provide concise, summative information in the form of a patient care summary. Flow sheets and graphic records permit concise documentation of nursing information and patient data over time. Records include documentation of routine observations or repeated specific measurements about the patient such as vital signs, intake and output, hygiene, and medication administration. DIF: Cognitive Level: Application REF: Text reference: p. 55 OBJ: Identify the purpose of the patient record. TOP: Discharge Summary Forms KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 8. Which is a delivery model that coordinates and links health care services to patients and families? a. Critical pathways b. Charting by exception c. SOAP d. Case management ANS: D Case management is a delivery model that coordinates and links health care services to patients and families while streamlining costs and maintaining quality. Critical pathways state the goals and important elements of care based on best practice and patient expectations by documenting, monitoring, and evaluating variances and providing resources and outcomes. This system involves completing a flow sheet that incorporates those standard assessment and intervention criteria by placing a check mark in the appropriate standard box on the flow sheet to indicate normal findings and routine interventions. The logic for SOAP (IE) notes is similar to that for the nursing process: Collect data about the patient’s problems, draw conclusions, and develop a plan of care. DIF: Cognitive Level: Analysis REF: Text reference: p. 57 OBJ: List guidelines for effective communication and reporting. TOP: Case Management KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Safe and Effective Care Environment 9. The patient has been in the hospital for a hip replacement. According to his critical pathway, he should have his Foley catheter discontinued on the fourth day after surgery. Instead, the patient has it removed on the third day and is voiding normally with no problems. This would be a sign of: a. a negative variance. b. positive case management. c. a positive variance. d. use of SBAR. ANS: C Variances are unexpected occurrences, unmet goals, and interventions not specified within the critical pathway time frame that reflect a positive or negative change. A positive variance occurs when a patient progresses more rapidly than is anticipated in the case management plan (e.g., use of a Foley catheter is discontinued a day early). A negative variance occurs when activities on the critical pathway do not happen as predicted, or outcomes are unmet (e.g., oxygen therapy is necessary for a new-onset breathing problem). Case management is a delivery model that coordinates and links health care services to patients and families while streamlining costs and maintaining quality. SBAR is a technique that provides a framework for communication between members of the health care team about a patient’s condition. SBAR is a concrete mechanism used for framing conversations, especially critical ones, requiring a nurse’s immediate attention and action. DIF: Cognitive Level: Analysis REF: Text reference: p. 59 OBJ: Describe the role of critical pathways in multidisciplinary documentation. TOP: Variances KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 10. Which is a primary difference between home care and hospital care? a. Documentation systems need to provide information for the home health nurse only. b. Documentation no longer affects reimbursement. c. Services are assumed and need less documentation. d. The patient and the family witness most of the care provided. ANS: D One primary difference is that the patient and the family rather than the nurse witness most of the care provided. Documentation systems need to provide the entire health care team with the necessary information to work together effectively, supply quality control, and justify reimbursement from Medicare, Medicaid, or private insurance companies. DIF: Cognitive Level: Analysis REF: Text reference: p. 59 OBJ: Explain guidelines used in documentation of home care and long-term care. TOP: Home Care Documentation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 11. The patient has been transferred to the nursing home from the acute care hospital. A report was called from the hospital and was received by the RN in charge of the nursing home unit. Upon arrival, which approach is used to assess the patient? a. The Long-Term Care Facility Resident Assessment Instrument b. The case management model c. Collaborative pathways d. The charting by exception model ANS: A Each resident in long-term care is assessed using the Long-Term Care Facility Resident Assessment Instrument as mandated by the Omnibus Budget Reconciliation Act of 1989 (OBRA) and updated in 1998. Case management is a delivery model that coordinates and links health care services to patients and families while streamlining costs and maintaining quality. The collaborative pathways are multidisciplinary care plans that include key interventions provided and expected outcomes within an established time frame. The charting by exception model involves completing a flow sheet that incorporates those standard assessment and intervention criteria by placing a check mark in the appropriate standard box on the flow sheet to indicate normal findings and routine interventions. DIF: Cognitive Level: Analysis REF: Text reference: p. 60 OBJ: Explain guidelines used in documentation of home care and long-term care. TOP: Long-Term Care Documentation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. The nursing assistant tells the RN that when the patient’s vital signs were taken, the patient complained that she was in a lot of pain. The nursing assistant then tells the nurse that she charted the patient’s complaint when she charted the vital signs. What instruction does the nurse need to provide to the nursing assistant? a. The nursing assistant needs to make sure she uses the SBAR format when entering notes. b. Nursing assistants are not allowed to chart vital signs. c. Only the nurse can write in the progress notes. d. The nursing assistant needs to write using blue ink to distinguish from the RN note. ANS: C The task of writing a progress note may not be delegated to nursing assistive personnel (NAP). The nurse instructs the NAP about what repetitive care activities should be documented on flow sheets, including vital signs, intake and output (I&O), and routine care related to ADLs. DIF: Cognitive Level: Analysis REF: Text reference: p. 61 OBJ: Identify the purpose of the patient record. TOP: Delegation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 13. The patient was in bed with all side rails up. During the night, the patient tried to get up to go to the bathroom and fell while trying to climb over the side rails. After meeting the patient’s needs and assessing that the patient was not harmed, what step should the nurse take (if any)? a. Complete an incident report and put it in the medical record. b. Chart what happened and state that an incident report has been filled out. c. Do nothing because the patient was not harmed. d. Document what happened in the patient record without mentioning the incident report. ANS: D Document in the patient’s record an objective description of what you observed and follow-up actions taken without reference to the incident report. Incident reports are not a part of the permanent medical record but are an important source of risk management data for identifying and addressing the causes of errors made in health care organizations. You complete the report even if an injury does not occur or is not apparent. DIF: Cognitive Level: Analysis REF: Text reference: p. 62 OBJ: Complete an incident report accurately. TOP: Incident Reports KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment MULTIPLE RESPONSE 1. Nursing documentation: (Select all that apply.) a. ensures continuity of care. b. provides legal evidence. c. evaluates patient outcomes. d. increases the risk of litigation. ANS: A, B, C Nursing documentation ensures continuity of care, provides legal evidence, and evaluates patient outcomes. Effective documentation ensures continuity of care, maintains standards, and reduces errors. DIF: Cognitive Level: Knowledge REF: Text reference: p. 47 OBJ: List guidelines for effective communication and reporting. TOP: Communication KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment 2. What is the goal of information management? (Select all that apply.) a. Support decision making. b. Improve patient outcomes. c. Ensure patient safety. d. Improve health care documentation. ANS: A, B, C, D The goal of information management is to support decision making and improve patient outcomes, improve health care documentation, ensure patient safety, and improve performance in patient care, treatment and services, governance, management, and support processes. DIF: Cognitive Level: Knowledge REF: Text reference: p. 49 OBJ: Identify the purpose of the patient record. TOP: Information Management KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. Nursing documentation must have which of the following characteristics? (Select all that apply.) a. Factual b. Organized c. Public d. Complete ANS: A, B, D Quality documentation and reporting have six characteristics: they are factual, accurate, complete, current, organized, and confidential. DIF: Cognitive Level: Comprehension REF: Text reference: p. 50 OBJ: List guidelines for effective communication and reporting. TOP: Guidelines for Reporting and Documentation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment COMPLETION 1. A patient’s private health information is legally protected by the ________________. ANS: Health Insurance Portability and Accountability Act (HIPAA) Health Insurance Portability and Accountability Act HIPAA HIPAA protects patients’ private health information. This governs all areas of health information management, including, for example, reimbursement, coding, security, and patient records. DIF: Cognitive Level: Application REF: Text reference: p. 49 OBJ: Describe measures to maintain confidentiality of patient information. TOP: Confidentiality KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 2. To limit liability, nursing documentation must clearly indicate that the nurse provided individualized, goal-directed nursing care to a patient based on the _____________________. ANS: nursing assessment To limit liability, nursing documentation must clearly indicate that the nurse provided individualized, goal-directed nursing care to a patient based on the nursing assessment. DIF: Cognitive Level: Application REF: Text reference: p. 50 OBJ: List guidelines for effective communication and reporting. TOP: Guidelines for Reporting and Documentation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 3. __________________ documentation should include your observations of patient behavior. ANS: Objective Objective documentation should include your observations of patient behavior. For example, objective signs of pain include increased pulse rate, increased respiration, diaphoresis, and guarding of a body part. DIF: Cognitive Level: Analysis REF: Text reference: p. 50 OBJ: List guidelines for effective communication and reporting. TOP: Objective Documentation KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe and Effective Care Environment 4. The abbreviation for every day (___) is no longer used. ANS: qd The abbreviation for every day (qd) is no longer used. If a treatment or medication is needed daily, the nurse should write out the word “daily” or “every day” on the written order or care plan. The abbreviation qd (every day) can be misinterpreted to mean O.D. (right eye). DIF: Cognitive Level: Application REF: Text reference: p. 51 OBJ: List guidelines for effective communication and reporting. TOP: Accurate Documentation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 5. When making written entries in the patient’s medical record, describe the nursing care provided and the ____________. ANS: patient’s response The information within a recorded entry or a report must be complete, containing appropriate and essential information. Make written entries in the patient’s medical record, describing nursing care that you administer and the patient’s response. DIF: Cognitive Level: Application REF: Text reference: p. 52 OBJ: List guidelines for effective communication and reporting. TOP: Complete Documentation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 6. ________________ provide a quick, easy reference for health care team members in assessing the patient’s status. ANS: Flow sheets Flow sheets provide a quick, easy reference for health care team members in assessing the patient’s status. DIF: Cognitive Level: Application REF: Text reference: p. 54 OBJ: Identify the purpose of the patient record. TOP: Flow Sheets and Graphic Records KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 7. Standardized care plans are effective ways to plan care for the patient. To be most effective, however, the SCP must be _________________. ANS: individualized to meet the patient’s needs Standardized care plans must be individualized for each patient. Most standardized care plans allow for the addition of specific patient outcomes and target dates for achievement of these outcomes. DIF: Cognitive Level: Application REF: Text reference: p. 54 OBJ: Identify the purpose of the patient record. TOP: Standardized Care Plans KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 8. Multidisciplinary care plans that include key interventions and expected outcomes within an established time frame are known as _______________. ANS: critical pathways Critical pathways are multidisciplinary care plans that include key interventions and expected outcomes within an established time frame. DIF: Cognitive Level: Comprehension REF: Text reference: p. 57 OBJ: Describe the role of critical pathways in multidisciplinary documentation. TOP: Critical Pathways KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Safe and Effective Care Environment 9. ___________________ provide a format for documenting a patient’s health status and progress. ANS: Progress notes Progress notes provide a format for documenting a patient’s health status and progress. DIF: Cognitive Level: Analysis REF: Text reference: p. 61 OBJ: Identify the purpose of the patient record. TOP: Patient Record KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment Chapter 8: Sterile Technique MULTIPLE CHOICE 1. When the following concepts are compared, which is most important in maintaining a safe environment by following aseptic principles? a. Performing a surgical hand scrub b. Applying a sterile gown c. Recognizing the importance of following aseptic principles d. Applying a mask and protective eyewear ANS: C A nurse in an operating room follows a series of steps toward sterile technique, such as applying a mask, protective eyewear, and a cap; performing a surgical hand scrub; and applying a sterile gown and sterile gloves. In contrast, a nurse who is performing a sterile dressing change at a patient’s bedside or in the home setting may only wash the hands and apply sterile gloves. Regardless of the procedures followed or the setting, the nurse needs to recognize the importance of following strict aseptic principles. DIF: Cognitive Level: Application REF: Text reference: p. 181 OBJ: Identify principles of surgical asepsis. TOP: Aseptic Principles KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse is preparing to provide wound care for her patient. She realizes that the most effective way to decrease the bacterial count on her hands is to wash her hands using: a. soap and water only. b. a nonalcohol antiseptic alone. c. a 50% alcohol-based antiseptic alone. d. a 60% to 95% alcohol-based antiseptic alone. ANS: D Studies have shown that antiseptics containing 60% to 95% alcohol alone, or 50% to 95% alcohol, when combined with other selected antiseptics (e.g., chlorhexidine), lower bacterial counts on the skin more effectively than do other antiseptics without alcohol. An alcohol-based hand rub may be used as a preoperative hand scrub after an initial 15-second prewash with plain soap and water. DIF: Cognitive Level: Synthesis REF: Text reference: p. 182 OBJ: Identify principles of surgical asepsis. TOP: Antiseptic Hand Wash KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. The nurse is applying for a job at a local hospital. She wants to look her best for the interview and decides to wear artificial nails. She does this knowing that artificial nails: a. are appropriate in the ICU setting as long as the nurse washes her hands frequently. b. can lead to fungal growth under the nail. c. can actually lower the bacterial count on the hands because they cover the natural nail. d. are banned only in areas where patients are critically ill. ANS: B Numerous reports identify that fungal growth frequently occurs under artificial nails as a result of moisture becoming trapped between the natural nail and the artificial nail. Because of the risks for infection posed by artificial nail use, health care workers who have direct contact with patients at high risk (e.g., those in intensive care units or operating rooms) should not wear artificial nails. Health care workers who wear artificial nails or nail extenders are more likely to harbor gram-negative pathogens on their fingertips, both before and after handwashing. Many health care institutions have chosen to ban artificial nails and extenders in all clinical areas, with the rationale that all patients are at risk for infection. DIF: Cognitive Level: Application REF: Text reference: p. 182 OBJ: Identify principles of surgical asepsis. TOP: Artificial Nails KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. When removing the mask after an aseptic procedure, what should the nurse do first? a. Remove gloves. b. Untie top strings of mask. c. Untie bottom strings of mask. d. Untie top strings and let mask hang. ANS: A Remove gloves first, if worn. This prevents contamination of hair, neck, and facial area by contaminants on gloves. Untie the top strings of the mask after untying the bottom strings. This prevents the top part of the mask from falling down over the clothing. If the mask falls and touches the clothing, it will be contaminated. DIF: Cognitive Level: Application REF: Text reference: p. 184 OBJ: Apply and remove a cap, mask, and eyewear correctly. TOP: Removing the Mask KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. An appropriate principle of surgical asepsis is that: a. the entirety of a sterile package is sterile once it is opened. b. all of the draped table, top to bottom, is considered sterile. c. an object held below the waist is considered contaminated. d. if the sterile barrier field becomes wet, the dry areas are still sterile. ANS: C A sterile object or field out of the range of vision or an object held below a person’s waist is contaminated. Once a sterile package is opened, a 2.5-cm (1-inch) border around the edges is considered unsterile. Tables draped as part of a sterile field are considered sterile only at table level. A sterile barrier that has been permeated by punctures, tears, or moisture must be considered contaminated. DIF: Cognitive Level: Application REF: Text reference: p. 182 OBJ: Perform the following skills: applying sterile gloves using open glove method, preparing a sterile field, applying a sterile drape correctly. TOP: Sterile Field KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. A patient requires a sterile dressing change for a mid-abdominal surgical incision. An appropriate intervention for the nurse to implement in maintaining sterile asepsis is to: a. put sterile gloves on before opening sterile packages. b. discard items that may have been in contact with the area below waist level. c. place the povidone-iodine bottle well within the sterile field. d. place sterile items on the very edge of the sterile drape. ANS: B A sterile object held below a person’s waist is considered contaminated. To maintain sterile asepsis, discard items that may have been in contact with the area below waist level. Sterile gloves are not put on before opening sterile packages, because the outside of the package is not sterile. The nurse uses hand hygiene and opens sterile packages while being careful to keep the inner contents sterile. Povidone-iodine and chlorhexidine are not considered sterile solutions and require separate work surfaces for prepping. The edges of a sterile field are considered to be contaminated. Sterile items should be placed in the middle of the sterile field to maintain sterile asepsis. DIF: Cognitive Level: Application REF: Text reference: p. 182 OBJ: Perform the following skills: applying sterile gloves using open glove method, preparing a sterile field, applying a sterile drape correctly. TOP: Sterile Field KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. Which patient may the nurse suspect will be at risk for a latex allergy? a. Patient with food allergies b. Patient with diabetes c. Patient with arthritis d. Patient with hypertension ANS: A Individuals at risk for latex allergy include those with a history of food allergies. Patients with diabetes, arthritis, and hypertension are not at increased risk for latex allergies. DIF: Cognitive Level: Application REF: Text reference: p. 191 OBJ: Identify individuals at risk for latex allergy. TOP: Latex Allergy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 8. Which of the following is an appropriate technique for the nurse to use when performing sterile gloving? a. Put the glove on the nondominant hand first. b. Interlock the hands after both gloves are applied. c. Pull the cuffs down on both gloves after gloving. d. Grasp the outside cuff of the other glove with the gloved hand. ANS: B After the second glove is on, interlock the hands above waist level. Be sure to touch only sterile sides. Gloving of the dominant hand first improves dexterity. The cuffs usually fall down after application. With a gloved dominant hand, slip fingers underneath the second glove’s cuff. The cuff protects gloved fingers. Sterile touching sterile prevents glove contamination. DIF: Cognitive Level: Application REF: Text reference: p. 194 OBJ: Perform the following skills: applying sterile gloves using open glove method, preparing a sterile field, applying a sterile drape correctly. TOP: Applying Sterile Gloves KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. The nurse is preparing to insert a urinary catheter. The package is dry but shows signs of yellowing inside the plastic wrapper, as if the package was wet at one time. What should the nurse do? a. Use the package because it is dry at present. b. Consider the outer package contaminated, but the inner package sterile. c. Discard the entire package as contaminated. d. Open the package and consider the 1-inch border as contaminated. ANS: C A sterile barrier that has been permeated by punctures, tears, or moisture must be considered contaminated. If there is any question or doubt of an item’s sterility, the item is considered to be unsterile. Once a sterile package has been opened, a 2.5-cm (1-inch) border around the edges is considered unsterile. DIF: Cognitive Level: Application REF: Text reference: p. 186 OBJ: Explain the importance of organization and caution when using surgical aseptic techniques. TOP: Principles of Surgical Asepsis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. A type I hypersensitivity to latex is evident if the nurse assesses: a. localized swelling. b. skin redness and itching. c. runny eyes and nose and cough. d. tachycardia, hypotension, and wheezing. ANS: D Type I allergic reaction is a true latex allergy that can be life threatening. Reactions vary on the basis of the type of latex protein and the degree of individual sensitivity, including local and systemic. Symptoms include hives, generalized edema, itching, rash, wheezing, bronchospasm, difficulty breathing, laryngeal edema, diarrhea, nausea, hypotension, tachycardia, and respiratory or cardiac arrest. Type IV hypersensitivity is a cell-mediated allergic reaction to chemicals used in latex processing. Reaction, including redness, itching, and hives, can be delayed up to 48 hours. Localized swelling, red and itchy or runny eyes and nose, and coughing may develop. Irritant dermatitis is a nonallergic response characterized by skin redness and itching. DIF: Cognitive Level: Comprehension REF: Text reference: p. 191 OBJ: Identify individuals at risk for latex allergy. TOP: Levels of Latex Reactions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. A nurse is preparing a sterile field for a dressing change using surgical aseptic technique. The nurse gathers supplies to prepare the sterile field using a packaged drape. Which option correctly describes how the nurse should set up the field? a. Don sterile gloves before opening the packaged drape. b. Clean the bottle of irrigation solution with alcohol before placing the bottle on the field. c. Avoid dropping sterile supplies close to the 1-inch border around the drape. d. Leave the sterile field unattended to obtain needed supplies. ANS: C The exterior border of the sterile drape is presumed contaminated, so all supplies must be kept within the sterile portion. Dropping supplies too close to the 1-inch border risks having them bounce off the sterile area. Nonsterile supplies are never to be placed on the sterile field. The sterile field is never to be out of the nurse's line of sight. Sterile gloves will not be applied until the sterile field is set up, and items needed to deliver care are ready for use. Applying them earlier in the process risks having them become contaminated. DIF: Cognitive Level: Application REF: Text reference: pp. 187-190 OBJ: Prepare a sterile field and use a sterile drape correctly. TOP: Using Surgical Asepsis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. Nurses commonly use surgical asepsis in which of the following situations? (Select all that apply.) a. In labor and delivery areas b. When inserting an intravenous catheter c. When treating patients with surgical incisions or burns d. When inserting a urinary catheter e. When dressing a MRSA-positive wound ANS: A, B, C, D Although nurses commonly practice surgical asepsis in operating rooms, labor and delivery areas, and major diagnostic or special procedure areas, they use surgical aseptic techniques at the patient’s bedside in three primary situations: (1) during procedures that require intentional perforation of a patient’s skin (e.g., insertion of intravenous [IV] catheters), (2) when the skin’s integrity is broken as the result of a surgical incision or burns, and (3) during procedures that involve insertion of devices or surgical instruments into normally sterile body cavities (e.g., insertion of a urinary catheter). DIF: Cognitive Level: Application REF: Text reference: p. 181 OBJ: Discuss settings in which you will use surgical aseptic techniques. TOP: Surgical Asepsis KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 2. The patient has just had a tracheostomy tube placed and is expectorating copious amounts of sputum that he coughs forcefully from his tracheostomy tube. The patient also is suspected of having methicillin-resistant Staphylococcus aureus (MRSA) in his sputum. The nurse is preparing to suction the patient to clear his airway. Which of the following will the nurse need to wear if following standard precautions? (Select all that apply.) a. Mask b. Goggles c. Gown d. Sterile gloves ANS: A, B, C, D Standard precautions are used for potential contact with blood and all body fluids. The use of standard precautions calls for the wearing of masks in combination with eye protection devices such as goggles or glasses with solid side shields whenever splashes, spray, splatter, or droplets of blood or other potentially infectious fluids may occur. These barriers keep the eyes, nose, and mouth free from exposure. Similarly, you wear gowns when there is risk of being splattered with blood or other infectious materials. All health care institutions need to provide to all employees at risk for exposure personal protective equipment and instructions for its use. DIF: Cognitive Level: Synthesis REF: Text reference: p. 182 OBJ: Identify principles of surgical asepsis. TOP: Standard Precautions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. A sterile field consists of which of the following? (Select all that apply.) a. Sterile tray b. Work surface draped with a sterile towel c. Table covered by a large sterile drape d. Patient’s bedside table ANS: A, B, C A sterile field may consist of a sterile kit or tray, a work surface draped with a sterile towel or wrapper, or a table covered with a large sterile drape. A patient’s bedside table is not sterile but can be a work surface where a sterile field can be applied. DIF: Cognitive Level: Application REF: Text reference: p. 186 OBJ: Perform the following skills: applying sterile gloves using open glove method, preparing a sterile field, applying a sterile drape correctly. TOP: Sterile Field KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION 1. _____________ is one practice designed to make and maintain objects and areas free from pathogenic microorganisms. ANS: Surgical asepsis Surgical asepsis or aseptic techniques and practices are designed to make and maintain objects and areas free from pathogenic microorganisms. DIF: Cognitive Level: Comprehension REF: Text reference: p. 181 OBJ: Describe conditions when you use surgical asepsis. TOP: Surgical Asepsis KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 2. The minimum standard for infection control as established by the Centers for Disease Control and Prevention (CDC) is _______________. ANS: standard precautions The Centers for Disease Control and Prevention has established standard precautions as the minimum standard for infection control. Standard precautions are used for potential contact with blood and all body fluids. DIF: Cognitive Level: Knowledge REF: Text reference: p. 182 OBJ: Discuss settings in which you will use surgical aseptic techniques. TOP: Standard Precautions KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 3. When performing sterile aseptic procedures, the nurse must create a _____________ in which objects can be handled with minimal risk for contamination. ANS: sterile field When performing sterile aseptic procedures, the nurse must have a work area in which objects can be handled with minimal risk for contamination. A sterile field serves such a purpose. DIF: Cognitive Level: Application REF: Text reference: p. 186 OBJ: Perform the following skills: applying sterile gloves using open glove method, preparing a sterile field, applying a sterile drape correctly. TOP: Sterile Field KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity OTHER 1. Which is the appropriate sequence to use when applying sterile attire? A. Apply sterile gloves. B. Secure hair. C. Don protective eyewear. D. Apply hair cover. E. Wash hands. F. Apply mask. ANS: E, B, D, F, C, A The correct sequence is wash hands, secure hair, apply hair cover, apply mask, don protective eyewear, apply sterile gloves. DIF: Cognitive Level: Application REF: Text reference: pp. 183-184 OBJ: Don sterile attire. TOP: Sterile Attire KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity