A nurse who created a sterile field for a patient is adding a sterile solution to the field. What is an appropriate action when performing this task? a. Place the bottle cap on the table with the edges down. b. Hold the bottle inside the edge of the sterile field. c. Hold the bottle with the label side opposite the palm of the hand. d. Pour the solution from a height of 4 to 6 inches (10 to 15 cm).

A nurse who created a sterile field for a patient is adding a sterile solution to the field. What is an appropriate action when performing this task? a. Place the bottle cap on the table with the edges down. b. Hold the bottle inside the edge of the sterile field. c. Hold the bottle with the label side opposite the palm of the hand. d. Pour the solution from a height of 4 to 6 inches (10 to 15 cm).

Comprehensive Medical Assisting: Administrative and Clinical Competencies (MindTap Course List)

6th Edition

ISBN:9781305964792

Author:Wilburta Q. Lindh, Carol D. Tamparo, Barbara M. Dahl, Julie Morris, Cindy Correa

Publisher:Wilburta Q. Lindh, Carol D. Tamparo, Barbara M. Dahl, Julie Morris, Cindy Correa

Chapter39: Phlebotomy

Section: Chapter Questions

Problem 3CR

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The nurse is cleaning an open abdominal wound that hasunapproximated edges. What are accurate steps in thisprocedure? Select all that apply. a. Use standard precautions or transmission-based precau-tions when indicated. b. Moisten a sterile gauze pad or swab with the prescribedcleansing agent and squeeze out excess solution.c. Clean the wound in full or half circles beginning on theoutside and working toward the center.d. Work outward from the incision in lines that are parallel toit from the dirty area to the clean area. e. Clean to at least one inch beyond the end of the new dress-ing if one is being applied. f. Clean to at least three inches beyond the wound if a newdressing is not being applied.
When using sterile technique to perform care of a new tracheostomy, which of the following is correct? a. Cleanse the area with hot soapy water, and rinse well. b. Clean the stoma under the faceplate with hydrogen peroxide. c. Cut a slit in sterile 4 ´ 4 inch gauze halfway through to make a dressing. d. Place the client in semi-Fowler’s position, if possible.
The nurse has opened the sterile supplies and put on two ster-ile gloves to complete a sterile dressing change, a procedure that requires surgical asepsis. The nurse must:a. Keep splashes on the sterile field to a minimum.b. Cover the nose and mouth with gloved hands if a sneeze isimminent.c. Use forceps soaked in a disinfectant.d. Consider the outer 1 inch of the sterile field ascontaminated.
A nurse is measuring the depth of a patient’s puncture wound.Which technique is recommended?a. Moisten a sterile, flexible applicator with saline and insertit gently into the wound at a 90-degree angle with the tipdown.b. Draw the shape of the wound and describe how deep itappears in centimeters.c. Gently insert a sterile applicator into the wound and moveit in a clockwise direction.d. Insert a calibrated probe gently into the wound and markthe point that is even with the surrounding skin surfacewith a marker.
A nurse is caring for a newly placed gastrostomy tube of apostoperative patient. Which nursing action is performedcorrectly?a. The nurse dips a cotton-tipped applicator into sterilesaline solution and gently cleans around the insertionsite.b. The nurse wets a washcloth and washes the area aroundthe tube with soap and water.c. The nurse adjusts the external disk every 3 hours to avoidcrusting around the tube.d. The nurse tapes a gauze dressing over the site aftercleansing it.
A nurse is providing patient teaching regarding the use ofnegative-pressure wound therapy. Which explanation providesthe most accurate information to the patient? a. The therapy is used to collect excess blood loss and pre-vent the formation of a scab. b. The therapy will prevent infection, ensuring that thewound heals with less scar tissue.c. The therapy provides a moist environment and stimulatesblood flow to the wound.d. The therapy irrigates the wound to keep it free from debrisand excess wound fluid.
A nurse is reconstituting powdered medication in a vial.Which action is a recommended step in this process? a. The nurse draws up the proper amount of powered medica-tion into the syringe. b. The nurse inserts the needle through the rubber stopper ofthe diluent vial.c. The nurse gently agitates the powdered medication vial tomix the powder and diluent completely.d. The nurse draws up the prescribed amount of medicationwhile holding the syringe horizontally at eye level.
When using a bovie around alcohol base preps, which of the following statements is correct? Select one: a. solution should be allowed to dry before activating cautery b. alcohol base prep solutions must never be used when using the ESU c. cautery sparks will not ignite alcohol vapors because it is considered low frequency electricity d. drapes must be saturated with sterile saline around incision site
A nurse is assisting a patient to empty and change an ostomyappliance. When the procedure is finished, the nurse notesthat the stoma is protruding into the bag. What would be thenurse’s first action in this situation?a. Reassure the patient that this is a normal finding with anew ostomy.b. Notify the primary care provider that the stoma isprolapsed.c. Have the patient rest for 30 minutes to see if the prolapseresolves.d. Remove the appliance and redo the procedure using alarger appliance.
A nurse is explaining to a patient the anticipated effect of the application of cold to an injured area. What response indi-cates that the patient understands the explanation? a. “I can expect to have more discomfort in the area wherethe cold is applied.”b. “I should expect more drainage from the incision after theice has been in place.”c. “I should see less swelling and redness with the coldtreatment.”d. “My incision may bleed more when the ice is firstapplied.”
Explain each: Why observe the following when doing ETS blood collection? a. Expiry date of blood collection tube b. Proper assembly of adapter, needle, and collection tubes Cleaning of puncture site in an inward to outward circular motion c. Puncture site after antiseptic has air dried d. Mixing blood and no pre-labelling of collection tubes e. Removal of tourniquet prior to needle drawing from vein f. Applying pressure to the site after blood collection
A nurse is flushing a patient’s implanted port after adminis-tering medications. The nurse observes that the port flushes, but does not have a blood return. What would be the nurse’snext action based on these findings?a. Gently push down on the needle and flush it a second time.b. Stop flushing and remove the needle; notify the primarycare provider.c. Ask the patient to perform a Valsalva maneuver; changethe patient position.d. Close the clamp; wait 3 minutes, try flushing the portagain.