A nurse assess the client to determine their risk for a health care-associated infection. Which hospitalized client is most at risk for developing this type of infection?

 LPN Progression Transition

Module 4 Wound Care, Asepsis, Sterile Technique and Foley Insertion Quiz

Question 1A nurse assess the client to determine their risk for a health care-associated infection. Which hospitalized client is most at risk for developing this type of infection?

 

A 20-year-old client who smokes two packs of cigarettes daily.

 

A 65-year-old client who has an indwelling urinary catheter.

 

 A 70-year-old client who is a vegetarian and slightly underweight.

 

 A 40-year-old client who has a white blood cell count of 6000/mm3.

 

Question 2Which of the following are expected practice(s) to prevent catheter associated urinary tract infections?  Select all that apply.

 

Document insertion date, indication and removal date.

 

 Prior to placement assess client for alternatives.

 

  Utilize clean gloves when inserting a urinary catheter.

 

 Promptly discontinue indwelling urinary catheters as soon as indications expire.

 

 Question 3The nurse realizes a supply is missing after setting up the sterile field. What is their next best action?

 

Call for help and do not leave the sterile field unattended.

 

 Leave the sterile field to retrieve the missing item.

 

 Perform the procedure with the supplies on hand.

 

 Discard the sterile field and prepare a new field with the needed supplies.

 

Question 4Choose the best practice for putting on sterile gloves.

 

Tuck sterile glove cuff into your gown or scrub shirt sleeve.

 

 Using clean hand slide fingers under cuff of sterile glove.

 

 When applying sterile gloves keep hands above waist level and away from non-sterile surfaces.

 

 Place the inner package of the sterile gloves labeled “cuff end” farthest from the body.

 

 Question 5What is the best way to assess a client for signs of urinary retention?

 

Use of a bladder scanner to determine urine volume in bladder.

 

 Gently palpate the supra-pubic area for bladder distention.

 

  Insert a foley catheter and note the amount of urine return.

 

 Percuss the supra-pubic area to determine urine volume.

 

 A portable bladder scanner is an accurate, reliable  and noninvasive device used to assess bladder volume.

 

Lynn, P. (2019) Taylor’s clinical nursing skills (5th ed.), Philadelphia PA: Wolters Kluwer p.662.

 

Question 6When performing a urinary catheterization on a female patient no urine flow is obtained and you note the catheter is in the vaginal orifice. What is the next best action?

 

Remove the catheter and reinsert into the urethra.

 

 zemove the catheter and have a more experienced nurse perform the catherization.

 

Leave the catheter in as a marker and start the procedure over.

 

 Remove the catheter and start the procedure over with a new catheter.

 

 Leave the catheter in place, obtain a new sterile catheter kit. Start procedure over and attempt to place a new catheter directly above the misplaced catheter. Once the new catheter is correctly in place, remove the catheter in the vaginal orifice. Because the risk of cross-infection, never remove a catheter from the vagina and insert into the urethra.

 

Lynn, P. (2019) Taylor’s clinical nursing skills (5th ed.), Philadelphia PA: Wolters Kluwer p. 676.

 

Question 7Which statement(s) represent best practice of urinary catheters? Select all that apply.

 

Remove a urinary catheter that is not necessary.

 

 Utilize a closed system which has a preconnected urinary catheter and collection system.

 

 Position the drainage bag even with the bladder.

 

 Wash your hands prior to inserting a urinary catheter.

 

 Question 8Prior to performing a urinary catheterization which of the following assessment(s) would be important? Select all that apply.

 

Assess for presence of urethra narrowing.

 

 Assess for activity limitations.

 

 Assess skin to determine type of catheter to use.

 

 Assess for allergies .

 

 Question 9The male client has an order to insertion of an indwelling urinary catheter. What consideration would the nurse keep in mind when performing this procedure?

 

   Since a closed system is used, the risk for urinary tract infection is absent.

 

 The male urethra is more easily injured during insertion.

 

 The catheter is inserted 2-3 inches into the urethra.

 

  In the hospital, a clean technique is used for catheter insertion.

 

 Question 10Which of the following statements are true about medical asepsis? Select all that apply.

 

   Clean least soiled area last.

 

 Clean least soiled area first.

 

Hand gels should be used before every client contact.

 

Hand washing should be used before every client contact.

 

 Question 11The nurse is teaching a group of newly hired unlicensed assistive personnel (UAP) about proper handwashing with soap and water. The nurse will know that the teaching was effective if a UAP demonstrates which behaviors? Select all that apply.

 

Vigorously rubs hands together for at least 15 seconds

 

 Uses a dry paper towel to turn off the faucet

 

   Removes all rings and watch before washing hands

 

Cleans underneath each fingernail

 

 Holds fingertips above the wrists while rinsing off the soap

 

 Question 12What is the most effective method to prevent the spread of infection among institutionalized patients?

 

Perform hand hygiene routinely.

 

Place patient on airborne precautions.

 

 Prevent contact with contaminated equipment.

 

 Decrease exposure to infections from family members.

 

 Question 13The nurse documents that the new wound has serosanguineous drainage. How is serosanguineous described?

 

Purulent Drainage

 

Straw Colored

 

 Bloody

 

Red, Watery, Clear

 

 Question 14The nurse is developing plan of care for the client with a stage 4 pressure ulcer, what would an applicable client goal/outcome be?

 

Wound will improve prior to discharge as evidenced by a decrease in drainage.

 

 Client will maintain intact skin throughout hospitalization.

 

 Client will limit pressure to wound site throughout treatment course.

 

   Wound will close with no evidence of infection within 6 weeks.

 

Question 15While donning sterile gloves, the nurse notices the edges of the glove package are slightly yellow. The yellow area is more than 1 inch away from the gloves and only appears to be on the outside of the glove package. What is the best action for the nurse to take at this point?

 

Throw away all supplies that were to be used, and begin again.

 

 Use the gloves and make sure the yellow edges of the package do not touch the client.

 

Remove the gloves from the sterile field, and use a new pair of sterile gloves.

 

Continue using the gloves inside the package because the package is intact.

 

 Question 16In which situation would using standard precautions be adequate?

 

While helping a client perform his or her own hygiene care, while in isolation for an airbourne pathogen.

 

 While taking vital signs for a client who has smallpox.

 

 While interviewing a client with a contagious productive cough

 

 While assessing sutures in an abdominal incision.

 

 Question 17What position should the female patient assume before the nurse inserts an indwelling urinary catheter?

 

Dorsal Recumbent

 

Modified Trendelenburg

 

 Semi-Fowlers

 

 Prone

 

Question 18A client has just voided 50 mL and yet reports that the bladder still feels full. The nurse’s next actions should include which of the following? Select all that apply.

 

Performing a bladder scan

 

 Inserting an incontinence pessary

 

 Applying a heating pad to the lower abdomen

 

 Obtaining a clean catch urine specimen

 

 Palpating the bladder height

 

 Question 19The nurse would expect which signs and symptoms for a patient with a suspected urinary tract infection (UTI)? Select all that apply.

 

Foul smelling urine

 

 Polyuria

 

 Urinary Frequency

 

 Upper abdominal pain

 

 Dysuria

 

 Question 20The nurse is assessing the client who presents to the outpatient clinic with an ischial wound that extends through the epidermis into the dermis. When documenting the depth of the wound, how would the nurse classify it?

 

Stage 2

 

Stage 4

 

 Stage 1

 

 Stage 3

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