ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 25 Questions
Question 1 of 5
A nurse is changing a patient's bed linens after drainage from an infected abdominal wound leaked. Which nursing action reflects proper use of medical asepsis?
Correct Answer: C
Rationale: According to the principles of medical asepsis, the nurse should move equipment and soiled items away from the body to prevent contaminated particles from settling on the hair, face, or uniform. The nurse should not put soiled items on the floor, as it is highly contaminated. The nurse should also clean the least soiled areas first, then move to the more soiled ones to prevent contamination.
Question 2 of 5
An outbreak of measles has occurred at the local elementary school. The parents of a child in the prodromal phase of the illness are told the child should stay home until well. What is important for the nurse to teach the parents about the prodromal phase?
Correct Answer: B
Rationale: During the prodromal stage, the person has vague signs and symptoms, such as fatigue and a low-grade fever. There are no obvious symptoms of infection during the incubation period, and symptoms are more specific and apparent during the full stage of illness, disappearing in the convalescent period.
Question 3 of 5
A nursing unit has multiple patients with MRSA infections requiring contact isolation. In which situations is it appropriate for the nurses to use an alcohol-based hand sanitizer to decontaminate their hands? Select all that apply.
Correct Answer: A,C,D,F
Rationale: An alcohol-based handrub is used in the following situations: before direct contact with patients; after direct contact with patient skin; after contact with body fluids if hands are not visibly soiled; after removing gloves; before inserting urinary catheters, peripheral vascular catheters, or invasive devices not requiring surgical placements; before donning sterile gloves prior to an invasive procedure; when moving from a contaminated body site to a clean body site; and after contact with objects contaminated by the patient. It is essential to note that handrubs are not appropriate for use after caring for a patient with C. diff infection.
Question 4 of 5
A nursing student is performing hand hygiene after providing care to a patient who is in isolation for C. diff related to antibiotic therapy. Which actions by the nursing student will the primary nurse need to correct? Select all that apply.
Correct Answer: B,D
Rationale: After caring for patients with C. diff infection, proper handwashing includes using soap and water, then rinsing thoroughly with water flowing toward fingertips. Proper hand hygiene permits a plain wedding band to be worn; other jewelry is removed. The nurse uses about 1 teaspoon (5 mL) of liquid soap, using friction motion for at least 20 seconds, washing to 1 inch above the wrists using friction. Keeping hands higher than elbows is incorrect as it allows water to run from less clean to more clean areas.
Question 5 of 5
When performing a dressing change requiring surgical asepsis, a nurse opens sterile supplies and dons sterile gloves. What additional action by the nurse is appropriate?
Correct Answer: A
Rationale: Avoiding splashing while pouring irrigant onto the sterile field is appropriate as moisture can contaminate the sterile field. Covering the nose and mouth with gloved hands during a sneeze would contaminate the gloves. Forceps soaked in disinfectant are not sterile. The outer 1 inch of the sterile field is considered contaminated, not sterile.