You are preparing to insert a urinary catheter. To perform this procedure, you will use:
a. Surgical asepsis
b. Medical asepsis
c.
Droplet precautions
d. Standard Precautions
Correct answer: a
Rationale: Inserting a urinary catheter requires sterile technique (surgical asepsis) to prevent the introduction of any
microorganisms into the urinary bladder during the procedure. Medical asepsis (clean technique) is used to reduce
the number or transmission of microorganisms and includes hand hygiene, wearing clean disposable gloves, etc.
Droplet precautions are a type of standard precautions in which the recommended barrier method includes the use of
a mask.
You are working in a busy emergency room. On entering station 1, you don a pair of clean disposable
gloves. You see that the patient has a gunshot wound to the chest and are concerned there may be
splattering of infectious materials. You apply goggles, a mask, and a gown. What is this called?
a. Following standard precautions
b. Airborne Precautions
c.
Contact Precautions
d. Protective Precautions
Correct answer: a
Rationale: You are demonstrating the use of standard precautions. Standard precautions are used to protect you
from potential contact with blood and body fluids. Since there is a risk of being splattered with infectious materials,
you should use gloves, a mask, eye protection, and a gown. Standard precautions should become a routine part of
your practice and thus be observed in every patient encounter. Medical asepsis (or clean technique) includes
procedures used to reduce the number and prevent the spread of microorganisms. Surgical asepsis (or sterile
technique) includes procedures used to eliminate all microorganisms from an area. Healthcare-associated infections
are those that develop as a result of a stay or visit in a health care facility and were absent at the time of admission.
The nurse manager is reviewing the use of standard precautions with the staff. Which of the following
should be included in the review? (Select all that apply.)
a. Standard precautions are used to protect you from potential contact with blood and body fluids.
b. Standard precautions should be observed in every patient encounter.
c.
Standard precautions refer only to the use of gloves, not to the use of masks, eye protection, or
gowns since these refer to other types of precautions.
d. To follow standard precautions, you must wear sterile gloves.
e. Always use standard precautions for c-diff
Correct answer: a,b
Rationale: Standard precautions are used to protect you from potential contact with blood and body fluids and should
be observed in every patient encounter. Besides gloving, standard precautions include the use of masks, eye
protection, and gowns when there is a risk of being splattered with infectious materials. Surgical asepsis (sterile
technique) requires the use of sterile gloves. Clean gloves may be worn when following standard precautions.
A nurse assists a patient with a Foley catheter to ambulate down the hall. The nurse holds the catheter
bag below the level of the patient’s bladder. What link in the chain of infection is the nurse breaking by
doing so?
a. Portal of exit
b. Portal of entry
c.
Reservoir
d. Host susceptibility
Correct answer: b
Rationale: By not allowing the urine from the bedside drainage bag to re-enter the bladder, the nurse is breaking the
chain of infection at the portal of entry. Emptying the bedside drainage bag may be an example of controlling the
reservoir. Host susceptibility has to do with issues such as age, nutritional status, medical treatments, immunizations,
and so on.
When should you perform hand hygiene? (Select all that apply.)
a. Before applying gloves to insert an IV
b. After documenting in the patient’s chart located at the nurse’s station
c.
After moving a patient up in bed
d. Before assessing a patient’s vital signs
e. Before touching clean linens
Correct answer: a, c, d
Rationale: You should perform hand hygiene before putting on sterile gloves and before inserting indwelling urinary
catheters, peripheral vascular catheters, or other invasive devices. You should perform hand hygiene after contact
with a patient’s intact skin (e.g., after assessing a patient’s vital signs or moving a patient in bed). Unless the hands
are visibly soiled, it is unnecessary to perform hand hygiene after documentation. If you touch an object that is not
visibly soiled, such as clean linens, hand washing is unnecessary at that time.
When is it acceptable to use antiseptic hand rub rather than soap and water? (Select all that apply.)
a. After adjusting a nasal cannula on a patient
b. After removing gloves after changing a wound dressing
c.
When the nurse’s hands are cracked from frequent hand hygiene
d. After moving patient’s belongings on the bedside table
e. After the patient develops a skin tear and blood is on the nurse’s hand
Correct answer: a, b, d
Rationale: When hands are visibly dirty or contaminated with proteinaceous material or visibly soiled with blood or
other body fluids, you need to wash your hands with soap and water. If hands are not visibly soiled, use an alcoholbased hand rub for routinely decontaminating hands, such as after contact with inanimate objects (including medical
equipment) in the immediate vicinity of a patient and after removing gloves. If repeated use of soaps or antiseptics
have caused dermatitis or cracked skin, the nurse should rinse and dry hands thoroughly after using soap and water
and avoid excessive amounts of soap or antiseptic. A hand lotion or barrier cream may be applied after hand hygiene