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final exam review questions

Terms in this set (55)

1.) Prior to performing the procedure, introduce self to client and verify the clients identity. 2 ways.
2.) Explain to client what you are about to do and why its necessary.
3.) Perform hand hygeine.
4.) Provide client privacy.
5.) Open package of sterile gloves. Place package of gloves on a clean, dry surface. If in an inner package of the gloves, open thm as well w/out contaminating the gloves or inner packages.
6.) Put the first glove on the dominant hand. IF the gloves are packaged so that they lie side by side, grasp the glove for the dominant hand by its folded cuffedgew/ thumb and first finger of the nondominant hand. Touch only the inside cuff. If the gloves are packaged one on top of the other, grasp the cuff of the top glove as above, using the opposite hand. Insert the dominant hand into the glove and pull the glove on. Keep the thumb of the inserted hand against the palm of the hand during insertion.
7.) Put the second glove on the nondominant hand. Pick up the other glove with the sterile gloved hand, inserting the gloved fingers under the cuff and holding the gloved thumb close to the gloved palm. Pull on the second glove carefully. Hold the thumb of the gloved first hand as far as possible from the palm.
8.) Remove and dispose of used gloves. There is no technique for removing sterile gloves that is different from nonsterile gloves. if solied w/ secretins remove by turning them inside out.
9.) Perform hand hygeine.
10.) Document that sterile technique was used in the performance of the procedure.
1.) Obtain assistance for changing a dressing on a restless or confused client. Assist the client to a comfortable position in which the wound can be readily exposed. Expose only the wound area, using a bath blanket to cover the client, if necessary. Make cuff on the mositure proof bag for disposal of soiled dressings and place bag within reach. Apply a face mask, if required.
2.) Introduce self to client. Verify clients identity and what you are about to do and why its necessary.
3.) Perform hand hygeine and observe other appropiate prevention control procedures.
4.) provide privacy for client.
5.) Remove binders and tape. Remove and dispose of soiled dressings appropiately. Apply clean gloves and remove the outer abdominal dressings or surgipad. Lift the outer dressing so that the undeside is away from the clients face. Place soiled dressings in the moisture proof bag w/out touching the outside of the bag. Remove the underdressings, taking care not to dislodge any drains. If the guaze sticks to the drain, support the drain w/ one hand and remove the guaze with other. Assess the location, type, color, cosistency, odor of wound drainage, and the number of guazes saturated or the diameter of drainage collected ont he dressings. Discard the soiled dressings in the bag mositure proof bag. Perform hand hygeine.
6.) Set up the sterile supplies. Open sterile dressing set, using surgical aseptic technique. Place the sterile drape beside the wound. Open the sterile cleaning solution and pour it over the guaze sponges in the plastic container. Apply sterile gloves.
7.) Clean the wound, if indicated. Clean the wound, using your gloved hands or forceps and guaze swabs moistened with cleaning solution. use a seperate awab for each stroke and discard. dry surrounding skin with dry guaze swabs as required. Dont dry the incision or wound itself.
8.) Apply dressings to the drain site and incision. Remove and discard gloves. Secure dressings with tape or ties. Perform hand hygeine.
9.) Document the procedure and all nursing assessments.
1.) Introduce seld and verify clients identity in 2 ways. Explain the procedure you are about to do and why its necessary.
2.) Perform hand hygeine and observe other appropiate infection prevention procedures.
3.) Provide for client privacy.
4.) Place the client in th appropiate position and drape all areas except the perineum.
-Male: Supine, thighs slightly abducted or apart.
-Female: Supine w/ knees flexed, feet about 2 feet apart, and hips slightly externally rotated, if possible.
5.) Establish adequate lightning. Stand on the clients right if you are right-handed, on the clients left if you are left handed.
6.) If using a collecting bag and its not contained w/in the catherization kit, open the drainage package and place the end of the tubing w/in reach.
7.) If agency policy permits, apply clean gloves and inject 10-15ml Xylocaine gel into the urethra of the male client. Wipe the underside of the penile shaft to distribute the gel up the urethra. Wait at least 5 minutes for the gel totake effect before inserting the catheter.
8.) Remove and discard gloves. PErform hand hygeine.
9.) Open the Catherization kit. Place a waterproof drape under the buttocks(female) or penis(male) w/out contaminating the center of the drape w/ your hands.
10.) Apply sterile gloves.
11.) Organize the remaining supplies: Saturate the cleansing balls with the antiseptic solution. Open the lubricant package. Remove the specimen container and place it nearby w/ the lid loosely on top.
12.) Attach the prefilled syringe to the indwelling catheter inflation hub. Apply agency policy and or/ manufacturer recommendation regarding protesting of the balloon.
13.) Lubricate the catheter 2.5-5cm(1-2in.) for females, 15-17cm(6-7in.) for males, and place it with the drainage end inside the collection container.
14.) If desired, place the fenestrated drape over th eperineum, exposing the urinary meatus.
15.) Cleanse the meatus.
-Females: use nondominant hand to spread labia so that the meatus is visible.
-MAles: use your nondominant hand to grasp the penis just below the glans. if necessary, retract the foreskin. Hold the penis firmly upright, with slight tension.
16.) Insert catheter. Grasp teh catheter firmly 5-7.5cm(2-3in.) from the tip. Ask the client to take a slow deep breath and insert the catheter as the client exhales. Slight resistance is expected as the cathter passes via sphicter. advance the catherter 5cm farther after urine begins to flow through it. If the catheter accidently slips into the vagina and labia its considered contaminated. You must discard and redo all over.
17.) Hold the catheter w/ the nondominant hand .
18.) For an indwelling catheter, inflate the retention balloon w/ the designated volume. w/out releasing the catheter, hold the inflation valve between 2 fingers of your nondominant hand while you attacha the syringe and inflate w/ your dominant hand. If the client complains of discomfort, immediately withdraw the instilled fluid, advance the catheter farther, and attempt to inflate the balloon again.
19.) Collect a urine specimen if needed. For a straight catheter, allow 20-30 ml to flow into bottle w/out touching the catheter to the bottle. For an indwelling catheter preattached to a drainage bag , a specimen may be taken from the bag this initial time only.
20.) Allow the straight cathter to continue draining into the urine receptacle.
21.) Examine and measure the urine. In some cases, only 750 to 1000ml of urine are to be drained from the bladder at one time.
22.) Remove the straught catheter when urine flow stops. secure the catheter to patients thigh.
23.) Hang bag below the level of the bladder. no tubing should fall below the top of the bag.
24.) wipe any remaining antiseptic or lubricant from the perineal area. replace teh foreskin if retracted earlier. return the client to a comfortable position. Instruct the client on positioning and moving w/ cathter in place.
25.) discard all used supplies in apporpiate receptacles.
26.) remove and discard gloves. Perform hand hygeine.
27.) Document the catherization procedure including atheter size and results in the client record using forms or checklists supplemented by narrative notes when appropiate.