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Terms in this set (65)
Standard precaution for measles
Standard precaution for pneumonia
Standard precautions for diarrhea for E. Coli
A nurse donning sterile gloves knows that the proper technique for gloving the dominant hand prevents contact between the contaminated hand and the non contaminated glove because
the inner edge of the cuff will lie against the skin and thus will not be sterile.
The correct actions when donning a pair of sterile gloves includes
Picking up the first glove by grasping it on the fold or cuff
the practice of making the environment and objects free of microorganisms
an agent that destroys, resists, or prevents the development of pathogens
Kills or inactivated nearly all organisms
Complete destruction of all forms of microbial life
Chemical compound used on skin or tissue to inhibit growth of microorganisms
One of the most effective ways to prevent the transfer of microorganisms from one person to another is to perform
When opening a sterile package you should
Hold it down with one hand while opening it
Drop the contents onto the sterile field without touching them
Pull the package apart equally with each hand
While waiting for sterile procedure to begin, how do you position your hands and arms?
With your hands clasped together in front of your body above waist level
the correct actions when donning a pair of sterile gloves
picking up the first glove by grasping it on the fold of the cuff
While performing a sterile dressing change on a patient correct technique must be regarded as broken if
Gloved hand touches the dressing table below the tabletop surface
Supplies are placed touching the edge of the sterile field
The nurse reaches over the sterile field when placing a swab used to clean the wound in the discard bag
When finished with a sterile procedure, unglove the outside surface of one glove at the cuff edge with the opposite gloves hand
when pouring sterile liquid, you should
Pour with the label toward the palm of the hand
What are the rules of asepsis?
Know what is sterile
Know what is not sterile
Separate sterile from unsterile
Remedy contamination immediately
For which procedure would sterile technique be unnecessary?
Insertion of NG tube into stomsch
You are about to open a sterile pack. Place the following steps in the proper sequence for opening the sterile pack.
Check package for integrity & expiration date
Catheter tubing should fall in a straight line from the edge of the bed into the collection bag
What information needs to be documented for urinary catheter insertion?
Amount, color, quality of urine returned
Patients response to procedure
Foley size &type, amount of water in balloon
Date and time
An indwelling urinary catheter has been ordered for a patient to relieve his symptoms until treatment can correct the situation. When a urinary catheter is left in place for more than a couple days in a male, it should be
Secured to the abdomen to decrease pressure on the penoscrotal angle
Urgency to void can lead to
When a patient is lying in bed, where do you place the Foley catheter tibing
Over the patients leg
There are several actions that help ensure success when catheterizing the male patient. When inserting the catheter into the penis, if resistances felt, an appropriate action is to
Tell him to take a deep breath and twist the catheter while inserting it
Hold the penis at a 90 degree angle (ow)
A nurse is planning on obtaining a urinary specimen from a patients closed urinary system. Identify the sequence of steps the nurse should make
1. Wipe the port with an alcohol swab
2.insert a 10mL syringe and needle into the port
3. Withdraw 5mL of urine
4. Transfer the urine to a specimen container
5. Transport the specimen to the lab
Does the nurse need to have a providers order to insert an urinary catheter?
A nurse is preparing to insert an indwelling urinate catheter for a female pt. When beginning the insertion procedure the nurse should instruct the patient to
a nurse is applying a condom cath for an older adult pt who is uncircumcised
leaving a space btwn the penis and catheters tip
It may be necessary to irrigate an indwelling catheter to maintain patency
a nurse who is preparing to insert a straight urinary catheter for a male pt should
apply light traction to the penis
R: lifting the penis to a position perpendicular to the body while applying light traction straightens the urethral canal to facilitate insertion
Dark amber urine indicates
Which of the following actions should a nurse take when removing a patients indwelling catheter
Deflate the balloon completely before removal
Incontinence is a normal part of aging
Average adult urine output
The nurse is assessing the insertion site on a central line. Which would need to be further investigated?
Erythema & tenderness
What is the name of the needle used to access a port?
PICC lines may be inserted in the
Basilic and cephalic veins
A nurse who chooses to uses a 3 mL syringe to flush a CVC device demonstrates a good understanding of the pressure to mL ratoo
False - should be 10 mL
Correct placement of subclavian catheters must be verified by X-ray before any fluid is infused
A nurse is preparing to obtain a blood sample from a patient who has a triple lumen central catheter in place for multiple therapies. Which of the following is an appropriate action for the nurse to take?
turn off the distal infusions for 1-5 minutes before obtaining the blood sample
Advantages of having a central line include
Decreased needle sticks
Allows for blood sampling
Multiple IV infusions
Scope of practice allows the LPN to draw from a PICC line for a patient 12 years old
A nurse is caring for a patient who has a central venous access device in place. Which of the following routine measures should the nurse use specifically to prevent lumen occlusion?
Clamping the extension tubing while removing a syringe from the injection cap
Choose the correct statements regarding central line dressing changes
Access caps need to be changed with dressing change
Must be completed every 7 days and PRN
If a central line catheter gets dislodged or malpositioned it could cause
An older adult patient who adheres to a regular cardiovascular rehab schedule that includes water aerobics and swimming requires long term venous access. Which of the following venous access device is the best choice for allowing him to continue his aquatic program?
A nurse has completed the dressing on a PICC line for a patient? What should the nurse put on the label?
Date time and initials
A nurse is caring for a patient who has a central venous catheter. When flushing catheter the nurse uses a 10 mL syringe to prevent which of the following complications associated with central vascular access devices?
What is the nurses primary responsibility in the daily care of a patient with a central line?
Flush the line according to agency policy
Catheter exit sites should be assessed for signs and symptoms of
Redness tenderness and drainage
The nurse should apply suction when inserting and withdrawing the suction catheter into the tracheotomy tube
The trach suctioning catheter port should not be occluded for more than _______ seconds when sucrioninf
What is used to facilitate the insertion of a tracheostomy tube and should be kept at the patients bedside?
High pitched, harsh or musical sounds but on inspiration
Curved guide for tracheostomy tube
cough or spit out phlegm from the throat or lungs
Tube for insertion into a cavity
For proper technique in suctioning the patient's tracheostomy, you would
Rotate the catheter and use suction while pulling the catheter out of the bronchus
Before performing trach care the LPN will place the patient in which position
chest physiotherapy - vibration
Increases turbulence of exhaled air and loosens secretions
chest physiotherapy - percussion
Dislodges secretions in the bronchial walls
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