A confused older-adult patient is wearing thick glasses and a hearing aid. Which intervention is the priority to facilitate communication? a. Focus on tasks to be completed b. Allow time for the patient to respond. c. Limit conversations with the patient.

A confused older-adult patient is wearing thick glasses and a hearing aid. Which intervention is the priority to facilitate communication? a. Focus on tasks to be completed b. Allow time for the patient to respond. c. Limit conversations with the patient. d. Use gestures and other nonverbal cues. - ans-b. Allow time for the patient to respond. OBJ:Engage in effective communication techniques for older patients The nurse asks a patient where the pain is, and the patient responds by pointing to the area of pain. Which form of communication did the patient use? a. Verbal b.Nonverbal c. Intonation d. Vocabulary - ans-b.Nonverbal OBJ: Demonstrate qualities, behaviors, and communication techniques of professional communication while interacting with patients. A nurse is implementing nursing care measures for patients' special communication needs. Which patient will need the most nursing care measures? a. The patient who is oriented, pain free, and blind b. The patient who is alert, hungry, and has strong self-esteem c. The patient who is cooperative, depressed, and hard of hearing d. The patient who is dyspneic, anxious, and has a tracheostom - ans-d. The patient who is dyspneic, anxious, and has a tracheostom OBJ: Implement nursing care measures for patients with special communication needs. A nurse is implementing nursing care measures for patients with challenging communication issues. Which types of patients will need these nursing care measures? (Select all that apply.) a. A child who is developmentally delayed b. An older-adult patient who is demanding c. A female patient who is outgoing and flirty d. A male patient who is cooperative with treatments e. An older-adult patient who can clearly see small print f. A teenager frightened by the prospect of impending surgery - ans-a. A child who is developmentally delayed b. An older-adult patient who is demanding c. A female patient who is outgoing and flirty f. A teenager frightened by the prospect of impending surgery OBJ: Implement nursing care measures for patients with special communication needs. A nurse is taking a history on a patient who cannot speak English. Which action will the nurse take? a. Obtain an interpreter. b. Refer to a speech therapist. c. Let a close family member talk. d. Find a mental health nurse specialist. - ans-a. Obtain an interpreter. OBJ: Implement nursing care measures for patients with special communication needs. A nurse is using SOLER to facilitate active listening. Which technique should the nurse use for R? a. Relax b. Respect c. Reminisce d. Reassure - ans-a. Relax OBJ: Demonstrate qualities, behaviors, and communication techniques of professional communication while interacting with patient Describe the technique SOLER An older-adult patient is wearing a hearing aid. Which technique should the nurse use to facilitate communication? a. Chew gum. b. Turn off the television. c. Speak clearly and loudly. d. Use at least 14-point print. - ans-b. Turn off the television. OBJ:Engage in effective communication techniques for older patients. A patient is aphasic, and the nurse notices that the patient's hands shake intermittently. Which nursing action is most appropriate to facilitate communication? a. Use a picture board. b. Use pen and paper. c. Use an interpreter. d. Use a hearing aid. - ans-a. Use a picture board. OBJ: Offer alternative communication devices when appropriate to promote communication with patients who have impaired communication. A patient just received a diagnosis of cancer. Which statement by the nurse demonstrates empathy? a."Tomorrow will be better. b."This must be hard news to hear." c."What's your biggest fear about this diagnosis?" d."I believe you can overcome this because I've seen how strong you are." - ans-b."This must be hard news to hear." OBJ: Identify opportunities to improve communication with patients while giving care. A patient says, "You are the worst nurse I have ever had." Which response by the nurse is most assertive? a."I think you've had a hard day." b."I feel uncomfortable hearing that statement." c."I don't think you should say things like that. It is not right." d."I have been checking on you regularly. How can you say that?" - ans-b."I feel uncomfortable hearing that statement." OBJ:Demonstrate qualities, behaviors, and communication techniques of professional communication while interacting with patients. A smiling patient angrily states, "I will not cough and deep breathe." How will the nurse interpret this finding? a. The patient's denotative meaning is wrong. b. The patient's personal space was violated. c. The patient's affect is inappropriate. d. The patient's vocabulary is poor. - ans-c. The patient's affect is inappropriate. OBJ:Demonstrate qualities, behaviors, and communication techniques of professional communication while interacting with patients. The staff is having a hard time getting an older-adult patient to communicate. Which technique should the nurse suggest the staff use? a. Try changing topics often. b. Allow the patient to reminisce. c. Ask the patient for explanations. d. Involve only the patient in conversations - ans-b. Allow the patient to reminisce. OBJ:Engage in effective communication techniques for older patients. When making rounds, the nurse finds a patient who is not able to sleep because of surgery in the morning. Which therapeutic response is most appropriate? a."You will be okay. Your surgeon will talk to you in the morning." b."Why can't you sleep? You have the best surgeon in the hospital." c."Don't worry. The surgeon ordered a sleeping pill to help you sleep." d."It must be difficult not to know what the surgeon will find. What can I do to help?" - ans-d."It must be difficult not to know what the surgeon will find. What can I do to help?" OBJ:Demonstrate qualities, behaviors, and communication techniques of professional communication while interacting with patients. Which behavior indicates the nurse is using a process recording correctly to enhance communication with patients? a. Shows sympathy appropriately b. Uses automatic responses fluently c. Demonstrates passive remarks accurately d. Self-examines personal communication skills - ans-d. Self-examines personal communication skills OBJ: Identify opportunities to improve communication with patients while giving care. Which behaviors indicate the nurse is using critical thinking standards when communicating with patients? (Select all that apply.) a. Instills faith b. Uses humility c. Portrays self-confidence d. Exhibits supportiveness e. Demonstrates independent attitude - ans-b. Uses humility c. Portrays self-confidence e. Demonstrates independent attitude OBJ: Identify ways to apply critical thinking to the communication process. Which situation will cause the nurse to intervene and follow up on the nursing assistive personnel's (NAP) behavior? a. The nursing assistive personnel is calling the older-adult patient "honey." b. The nursing assistive personnel is facing the older-adult patient when talking. c. The nursing assistive personnel cleans the older-adult patient's glasses gently. d. The nursing assistive personnel allows time for the older-adult patient to respond. - ans-a. The nursing assistive personnel is calling the older-adult patient "honey." OBJ:Engage in effective communication techniques for older patients. Which types of nurses make the best communicators with patients? a. Those who learn effective psychomotor skills b. Those who develop critical thinking skills c. Those who like different kinds of people d. Those who maintain perceptual biases - ans-b. Those who develop critical thinking skills OBJ: Identify ways to apply critical thinking to the communication process. Explain the relationship between the infection chain and transmission of infection - ans-Infection chain cycle: infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, host -An infection will develop if this chain remains uninterrupted Give an example of preventing infection for each element of the infection chain - ans--infectious agent: washing hands with soap and water or an alcohol-based hand product -Reservoir: Keeping wounds in the light or turning the A/C at a temperature below 68*F -Portal of Exit: Standard, contact, and droplet precautions -Modes of Transmission: allows make sure food is fully cooked and safe to consume -Portal of Entry: keep wounds covered so there is no contact with bacteria -Host: do not take antibiotics frequently and do not smoke Identify the normal defenses of the body against infection. - ans--Normal floras do not usually cause disease when residing in their usual area of the body but help to maintain health -body system defenses: each organ system has defense mechanisms physiologically suited to their specific structure and function -inflammation: protective vascular reaction that delivers fluid, blood products, and nutrients to an area of injury which neutralizes and eliminates pathogens or dead tissues and establishes a means of repairing body cells and tissues. Discuss the events in the inflammatory response. - ans-acute inflammation is an immediate response to cellular injury. Rapid vasodilation occurs, allowing more blood near the location of the injury. increase in blood flow causes redness and localized warmth at site. May cause swelling of fluid, pain, temporary loss of function. WBCs arrive at spot and phagocytosis occurs causing an increase in WBCs and fever. Platelets and plasma proteins form a meshlike matrix at site of inflammation. Tissue also repairs itself by regrowing. Identify patients most at risk for infection. - ans-babies, older age, poor nutrition, stress, inherited conditions, chronic disease, and treatments or conditions that compromise the immune response increase susceptibility to infection, critical illnesses-diabetes mellitus or cancer, MS -IV catheters or indwelling urinary catheters -leukemia, AIDS, lymphoma, aplastic anemia, HIV-burns Describe the signs/symptoms of a localized infection and those of a systemic infection. - ans--Localized infections are most common in areas of skin or mucous membrane breakdown such as surgical and traumatic wounds, pressure ulcers, oral lesions, and abscesses. Symptoms include redness, warmth, and swelling, drainage from open lesions or wounds, tenderness, possible restriction of movement -Systemic infections cause more generalized symptoms than local infection. Symptoms include fever, fatigue, nausea/vomiting, malaise, swollen lymph nodes. Elevation in body temp can cause increased heart and respiratory rates and low BP. Explain conditions that promote the transmission of health care-associated infections. - ans-invasive procedures, antibiotic administration, presence of multidrug-resistant organisms, and breaks in infection prevention and control activities -surgical or traumatic wounds, urinary and respiratory tracts, and bloodstream Explain the difference between medical and surgical asepsis - ans--Medical asepsis techniques break the chain of infection (use even when there is no infection). Uses hand hygiene, barrier techniques, routine environmental cleaning -Surgical asepsis prevents contamination of an open wound, serves to isolate an operative area from the unsterile environment, and maintains a sterile field for surgery. Uses procedures to eliminate all microbes from an object or area. Used in OR, labor and delivery area, major diagnostic ways, and at patients bedside Explain the rationale for standard precautions - ans-Precautions set in place to protect the patient and provide protection for the health care worker. Applies to contact with blood, body fluid, nonitact skin, and mucous membranes To prevent control infection transmission. Apply to contact with blood, body fluid, non intact skin, and mucous membranes. Protect patients and provide protection for health care workers. ALWAYS BE USED! Perform proper procedures for hand hygiene - ans-vigorous, brief rubbing together of all surfaces of lathered hands, followed by rinsing under a stream of warm water for at least 15 seconds Explain how infection control measures differ in the home versus the hospital. - ans-In a hospital, a sterile processing department is responsible for disinfecting and sterilization of reusable items. Nurses in home health have to perform this themselves. -Cleaning: rinse in cold water, wash with soap and warm water, rinse thoroughly, use brush to remove dirt (open hinges), rinse in warm water, dry object and prepare for disinfection or sterilization, clean sink, brush, and gloves according. -disinfection eliminates many or all microbes except bacterial spores -sterilization eliminates or destroys all forms of microscopic life using steam, dry heat, hydrogen peroxide plasma, ethylene oxide (ETO) Define the nursing process and explain how nurses use the nursing process. - ans-Critical thinking process that professional nurses us to apply the nest available evidence to caregiving and promoting human functions and responses to heath and illness Match nursing actions with the step of the nursing process Assess Diagnose Planning Implementation Evaluate A) Gather information about the patient condition B) Identify the patient's problem C) Set goals of care and desired outcomes and identify appropriate nursing actions D) Perform the nursing actions identified in planning E) Determine if goals and expected outcomes are achieved - ans-Assess) A) Gather information about the patient condition Diagnose) B) Identify the patient's problem Planning) C) Set goals of care and desired outcomes and identify appropriate nursing actions Implementation) D) Perform the nursing actions identified in planning Evaluate) E) Determine if goals and expected outcomes are achieved Correctly identify subjective and objective data - ans-1. Subjective Data:-referred to as symptoms or covert data-what the patient tells you-can only be described & verified by person affected 2. Objective Data:--what nurse observes-detectable by observer-can be measured or tested against accepted standard-obtained by observation or physical examination-nurse obtains objective data to validate subject data Identify the necessary elements of correctly written goals - ans-1) Must be patient centered 2) Use SMART acronym Specific Measurable Attainable Realistic Timed Describe two different types and sources of data - ans-Data Documentation) Use clear, concise appropriate terminology Concept Mapping) Visual representation that allows toy to graphically show connections among a patient's many health problems Prioritize the nursing assessments in patients - ans-High) Emergent Intermediate) Non Life threatening Low) Affect patient's future well-being Identify interpendent, dependent, and interdependent interventions - ans-Nurse Initiated) Independent Actions that nurse initiates Health Care provider initiated) Dependent- Require an order from a physical or other heath care professional Collaborative) Interdependent-- Require combined knowledge, skill, and expertise of multiple heath care professionals Compare contrast standing and stat order - ans-Standing order) Standing orders are written protocols that authorize designated members of the health care team A stat order is used in a critical or life-threatening situation. Often, stat orders should be carried out right now, before any other task. Discuss the relationship of the nursing process to critical thinking - ans-Nursing Process is a systematic, rational method of planning and providing care which requires critical thinking skills to identify and treat actual or potential health problems and to promote wellness. It provides a framework for the nurses to be responsible and accountable. When working with an older adult who is hearing-impaired, the use of which techniques would improve communication? (Select all that apply.) 1. Check for needed adaptive equipment. 2. Exaggerate lip movements to help the patient lip read. 3. Give the patient time to respond to questions. 4. Keep communication short and to the point. 5. Communicate only through written information. - ans-1. Check for needed adaptive equipment. 3. Give the patient time to respond to questions. 4. Keep communication short and to the point. Nurses must communicate effectively with the health care team for which of the following reasons? (Select all that apply.) 1. Improve the nurse's status with the health team members 2. Reduce the risk of errors to the patient 3. Provide optimum level of patient care 4. Improve patient outcomes 5. Prevent issues that need to be reported to outside agencies - ans-2. Reduce the risk of errors to the patient 3. Provide optimum level of patient care 4. Improve patient outcomes A new nurse complains to her preceptor that she has no time for therapeutic communication with her patients. Which of the following is the best strategy to help the nurse find more time for this communication? 1. Include communication while performing tasks such as changing dressings and checking vital signs. 2. Ask the patient if you can talk during the last few minutes of visiting hours. 3. Ask Pastoral care to come back a little later in the day. 4. Remind the nurse to complete all her tasks and then set up remaining time for communication. - ans-1. Include communication while performing tasks such as changing dressings and checking vital signs. Motivational interviewing (MI) is a technique that applies understanding a patient's values and goals in helping the patient make behavior changes. What are other benefits of using MI techniques? (Select all that apply.) 1. Gaining an understanding of patient's motivations 2. Focusing on opportunities to avoid poor health choices 3. Recognizing patient's strengths and supporting their efforts 4. Providing assessment data that can be shared with families to promote change 5. Identifying differences in patient's health goals and current behaviors - ans-1. Gaining an understanding of patient's motivations 3. Recognizing patient's strengths and supporting their efforts 5. Identifying differences in patient's health goals and current behaviors A nurse is talking with a young-adult patient about the purpose of a new medication. The nurse says, "I want to be clear. Can you tell me in your words the purpose of this medicine?" This exchange 334is an example of which element of the transactional communication process? 1. Message 2. Obtaining feedback 3. Channel 4. Referent - ans-2. Obtaining feedback A patient who is Spanish-speaking does not appear to understand the nurse's information on wound care. Which action should the nurse take? 1. Arrange for a Spanish-speaking social worker to explain the procedure 2. Ask a fellow Spanish-speaking patient to help explain the procedure 3. Use a professional interpreter to provide wound care education in Spanish 4. Ask the patient to write down questions that he or she has for the nurse - ans-3. Use a professional interpreter to provide wound care education in Spanish A nurse prepares to contact a patient's physician about a change in the patient's condition. Put the following statements in the correct order using SBAR (Situation, Background, Assessment, and Recommendation) communication. 1. "She is a 53-year-old female who was admitted 2 days ago with pneumonia and was started on Levaquin at 5 PMyesterday. She complains of a poor appetite." 2. "The patient reported feeling very nauseated after her dose of Levaquin an hour ago." 3. "Would you like to make a change in antibiotics, or could we give her a nutritional supplement before her medication?" 4. "The patient started complaining of nausea yesterday evening and has vomited several times during the night." - ans-4 S. "The patient started complaining of nausea yesterday evening and has vomited several times during the night." 1. B "She is a 53-year-old female who was admitted 2 days ago with pneumonia and was started on Levaquin at 5 PMyesterday. She complains of a poor appetite." 2. A "The patient reported feeling very nauseated after her dose of Levaquin an hour ago." 3. R "Would you like to make a change in antibiotics, or could we give her a nutritional supplement before her medication?" A nurse is assigned to care for a patient for the first time and states, "I don't know a lot about your culture and want to learn how to better meet your health care needs." Which therapeutic communication technique did the nurse use in this situation? 1. Validation 2. Empathy 3. Sarcasm 4. Humility - ans-4. Humility A new nurse is experiencing lateral violence at work. Which steps could the nurse take to address this problem? 1. Challenge the nurses in a public forum to embarrass them and change their behavior 2. Talk with the department secretary and ask if this has been a problem for other nurses 3. Talk with the preceptor or manager and ask for assistance in handling this issue 4. Say nothing and hope things get better - ans-3. Talk with the preceptor or manager and ask for assistance in handling this issue A nurse has been gathering physical assessment data on a patient and is now listening to the patient's concerns. The nurse sets a goal of care that incorporates the patient's desire to make treatment decisions. This is an example of the nurse engaged in which phase of the nurse-patient relationship? 1. Working phase 2. Preinteraction phase 3. Termination phase 4. Orientation phase - ans-1. Working phase A patient is evaluated in the emergency department after causing an automobile accident while being under the influence of alcohol. While assessing the patient, which statement would be the most therapeutic? 1. "Why did you drive after you had been drinking?" 2. "We have multiple patients to see tonight as a result of this accident." 3. "Tell me what happened before, during, and after the automobile accident tonight." 4. "It will be okay. No one was seriously hurt in the accident." - ans-3. "Tell me what happened before, during, and after the automobile accident tonight." A nursing student is reviewing a process recording with the instructor. The student engaged the patient in a discussion about availability of family members to provide support at home once the patient is discharged. The student reviews with the instructor whether the comments used encouraged openness and allowed the patient to "tell his story." This is an example of which step of the nursing process? 1. Planning 2. Assessment 3. Intervention 4. Evaluation - ans-4. Evaluation Which strategies should a nurse use to facilitate a safe transition of care during a patient's transfer from the hospital to a skilled nursing facility? (Select all that apply.) 1. Collaboration between staff members from sending and receiving departments 2. Requiring that the patient visit the facility before a transfer is arranged 3. Using a standardized transfer policy and transfer tool 4. Arranging all patient transfers during the same time each day 5. Relying on family members to share information with the new facility - ans-1. Collaboration between staff members from sending and receiving departments 3. Using a standardized transfer policy and transfer tool The nurse uses silence as a therapeutic communication technique. What is the purpose of the nurse's silence? (Select all that apply.) 1. Prevent the nurse from saying the wrong thing 2. Prompt the patient to talk when he or she is ready 3. Allow the patient time to think and gain insight 4. Allow time for the patient to drift off to sleep 5. Determine if the patient would prefer to talk with another staff member - ans-2. Prompt the patient to talk when he or she is ready 3. Allow the patient time to think and gain insight What is the most effective way to control transmission of infection? 1. Isolation precautions 2. Identifying the infectious agent 3. Hand hygiene practices 4. Vaccinations - ans-3. Hand hygiene practices A patient who has been isolated for Clostridium difficile (C. difficile) asks you to explain what he should know about this organism. What is the most appropriate information to include in patient teaching? (Select all that apply.) 1. The organism is usually transmitted through the fecal-oral route. 2. Hands should always be cleaned with soap and water versus alcohol-based hand sanitizer. 3. Everyone coming into the room must be wearing a gown and gloves. 4. While the patient is in contact precautions, he cannot leave the room. 5. C. difficile dies quickly once outside the body - ans-1. The organism is usually transmitted through the fecal-oral route. 2. Hands should always be cleaned with soap and water versus alcohol-based hand sanitizer. 3. Everyone coming into the room must be wearing a gown and gloves. Your assigned patient has a leg ulcer that has a dressing on it. During your assessment you find that the dressing is saturated with purulent drainage. Which action would be best on your part? 1. Reinforce dressing with a clean, dry dressing and call the health care provider. 2. Remove wet dressing and apply new dressing using sterile procedure. 3. Put on gloves before removing the old dressing; then obtain a wound culture. 4. Remove saturated dressing with gloves, remove gloves, then perform hand hygiene and apply new gloves before putting on a clean dressing. - ans-4. Remove saturated dressing with gloves, remove gloves, then perform hand hygiene and apply new gloves before putting on a clean dressing. A patient is diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. Which type of isolation precaution is most appropriate for this patient? 1. Reverse isolation 2. Droplet precautions 3. Standard precautions 4. Contact precautions - ans-2. Droplet precautions A family member is providing care to a loved one who has an infected leg wound. What should the nurse instruct the family member to do after providing care and handling contaminated equipment or organic material? 1. Wear gloves before eating or handling food. 2. Place any soiled materials into a bag and double bag it. 3. Have the family member check with the health care provider about need for immunization. 4. Perform hand hygiene after care and/or handling contaminated equipment or material. - ans-4. Perform hand hygiene after care and/or handling contaminated equipment or material. A patient is isolated for pulmonary tuberculosis. The nurse notes that the patient seems to be angry, but he knows that this is a normal response to isolation. Which is the best intervention? 1. Provide a dark, quiet room to calm the patient. 2. Reduce the level of precautions to keep the patient from becoming angry. 3. Explain the reasons for isolation procedures and provide meaningful stimulation. 4. Limit family and other caregiver visits to reduce the risk of spreading the infection. - ans-3. Explain the reasons for isolation procedures and provide meaningful stimulation. When should a nurse wear a mask? (Select all that apply.) 1. The patient's dental hygiene is poor. 2. The nurse is assisting with an aerosolizing respiratory procedure such as suctioning. 3. The patient has acquired immunodeficiency syndrome (AIDS) and a congested cough. 4. The patient is in droplet precautions. 5. The nurse is assisting a health care provider in the insertion of a central line catheter. - ans-2. The nurse is assisting with an aerosolizing respiratory procedure such as suctioning. 4. The patient is in droplet precautions. 5. The nurse is assisting a health care provider in the insertion of a central line catheter. Which type of personal protective equipment are staff required to wear when caring for a pediatric patient who is placed into airborne precautions for confirmed chickenpox/herpes zoster? (Select all that apply.) 1. Disposable gown 2. N 95 respirator mask 3. Face shield or goggles 4. Surgical mask 5. Gloves - ans-1. Disposable gown 2. N 95 respirator mask 5. Gloves The infection control nurse has asked the staff to work on reducing the number of iatrogenic infections on the unit. Which of the following actions on your part would contribute to reducing health care-acquired infections? (Select all that apply.) 1. Teaching correct handwashing to assigned patients 2. Using correct procedures in starting and caring for an intravenous infusion 3. Providing perineal care to a patient with an indwelling urinary catheter 4. Isolating a patient who has just been diagnosed as having tuberculosis 5. Decreasing a patient's environmental stimuli to decrease nausea - ans-1. Teaching correct handwashing to assigned patients 2. Using correct procedures in starting and caring for an intravenous infusion 3. Providing perineal care to a patient with an indwelling urinary catheter Which of the following actions by the nurse comply with core principles of surgical asepsis? (Select all that apply.) 1. Set up sterile field before patient and other staff come to the operating suite. 2. Keep the sterile field in view at all times. 3. Consider the outer 2.5 cm (1 inch) of the sterile field as contaminated. 4. Only health care personnel within the sterile field must wear personal protective equipment. 5. The sterile gown must be put on before the surgical scrub is performed. - ans-2. Keep the sterile field in view at all times. 3. Consider the outer 2.5 cm (1 inch) of the sterile field as contaminated. A patient has an indwelling urinary catheter. Why does an indwelling urinary catheter present a risk for urinary tract infection? (Select all that apply.) 1. It allows migration of organisms into the bladder. 2. The insertion procedure is not done under sterile conditions. 3. It obstructs the normal flushing action of urine flow. 4. It keeps an incontinent patient's skin dry. 5. The outer surface of the catheter is not considered sterile. - ans-1. It allows migration of organisms into the bladder. 3. It obstructs the normal flushing action of urine flow. Put the following steps for removal of protective barriers after leaving an isolation room in order. 1. Remove gloves. 2. Perform hand hygiene. 3. Remove eyewear or goggles. 4. Untie top and then bottom mask strings and remove from face. 5. Untie waist and neck strings of gown. Remove gown, rolling it onto itself without touching the contaminated side. - ans-1. Remove gloves. 3. Remove eyewear or goggles. 5. Untie waist and neck strings of gown. Remove gown, rolling it onto itself without touching the contaminated side. 4. Untie top and then bottom mask strings and remove from face. 2. Perform hand hygiene. What does it mean when a patient is diagnosed with a multidrug-resistant organism in his or her surgical wound? (Select all that apply.) 1. There is more than one organism in the wound that is causing the infection. 2. The antibiotics the patient has received are not strong enough to kill the organism. 3. The patient will need more than one type of antibiotic to kill the organism. 4. The organism has developed a resistance to one or more broad-spectrum antibiotics, indicating that the organism will be hard to treat effectively. 5. There are no longer any antibiotic options available to treat the patient's infection. - ans-2. The antibiotics the patient has received are not strong enough to kill the organism. 4. The organism has developed a resistance to one or more broad-spectrum antibiotics, indicating that the organism will be hard to treat effectively. A patient's surgical wound has become swollen, red, and tender. The nurse notes that the patient has a new fever, purulent wound drainage, and leukocytosis. Which interventions would be appropriate and in what order? 1. Notify the health care provider of the patient's status. 2. Reassure the patient and recheck the wound later. 3. Support the patient's fluid and nutritional needs. 4. Use aseptic technique to change the dressing. - ans-4. Use aseptic technique to change the dressing. 2. Reassure the patient and recheck the wound later. 1. Notify the health care provider of the patient's status. 3. Support the patient's fluid and nutritional needs. 15. Which of these statements are true regarding disinfection and cleaning? (Select all that apply.) 1. Proper cleaning requires mechanical removal of all soil from an object or area. 2. General environmental cleaning is an example of medical asepsis. 3. When cleaning a wound, wipe around the wound edge first and then clean inward toward the center of the wound. 4. Cleaning in a direction from the least to the most contaminated area helps reduce infections. 5. Disinfecting and sterilizing medical devices and equipment involve the same procedures. - ans-1. Proper cleaning requires mechanical removal of all soil from an object or area. 2. General environmental cleaning is an example of medical asepsis. 4. Cleaning in a direction from the least to the most contaminated area helps reduce infections.A confused older-adult patient is wearing thick glasses and a hearing aid. Which intervention is the priority to facilitate communication? a. Focus on tasks to be completed b. Allow time for the patient to respond. c. Limit conversations with the patient. d. Use gestures and other nonverbal cues. - ans-b. Allow time for the patient to respond. OBJ:Engage in effective communication techniques for older patients The nurse asks a patient where the pain is, and the patient responds by pointing to the area of pain. Which form of communication did the patient use? a. Verbal b.Nonverbal c. Intonation d. Vocabulary - ans-b.Nonverbal OBJ: Demonstrate qualities, behaviors, and communication techniques of professional communication while interacting with patients. A nurse is implementing nursing care measures for patients' special communication needs. Which patient will need the most nursing care measures? a. The patient who is oriented, pain free, and blind b. The patient who is alert, hungry, and has strong self-esteem c. The patient who is cooperative, depressed, and hard of hearing d. The patient who is dyspneic, anxious, and has a tracheostom - ans-d. The patient who is dyspneic, anxious, and has a tracheostom OBJ: Implement nursing care measures for patients with special communication needs. A nurse is implementing nursing care measures for patients with challenging communication issues. Which types of patients will need these nursing care measures? (Select all that apply.) a. A child who is developmentally delayed b. An older-adult patient who is demanding c. A female patient who is outgoing and flirty d. A male patient who is cooperative with treatments e. An older-adult patient who can clearly see small print f. A teenager frightened by the prospect of impending surgery - ans-a. A child who is developmentally delayed b. An older-adult patient who is demanding c. A female patient who is outgoing and flirty f. A teenager frightened by the prospect of impending surgery OBJ: Implement nursing care measures for patients with special communication needs. A nurse is taking a history on a patient who cannot speak English. Which action will the nurse take? a. Obtain an interpreter. b. Refer to a speech therapist. c. Let a close family member talk. d. Find a mental health nurse specialist. - ans-a. Obtain an interpreter. OBJ: Implement nursing care measures for patients with special communication needs. A nurse is using SOLER to facilitate active listening. Which technique should the nurse use for R? a. Relax b. Respect c. Reminisce d. Reassure - ans-a. Relax OBJ: Demonstrate qualities, behaviors, and communication techniques of professional communication while interacting with patient Describe the technique SOLER An older-adult patient is wearing a hearing aid. Which technique should the nurse use to facilitate communication? a. Chew gum. b. Turn off the television. c. Speak clearly and loudly. d. Use at least 14-point print. - ans-b. Turn off the television. OBJ:Engage in effective communication techniques for older patients. A patient is aphasic, and the nurse notices that the patient's hands shake intermittently. Which nursing action is most appropriate to facilitate communication? a. Use a picture board. b. Use pen and paper. c. Use an interpreter. d. Use a hearing aid. - ans-a. Use a picture board. OBJ: Offer alternative communication devices when appropriate to promote communication with patients who have impaired communication. A patient just received a diagnosis of cancer. Which statement by the nurse demonstrates empathy? a."Tomorrow will be better. b."This must be hard news to hear." c."What's your biggest fear about this diagnosis?" d."I believe you can overcome this because I've seen how strong you are." - ans-b."This must be hard news to hear." OBJ: Identify opportunities to improve communication with patients while giving care. A patient says, "You are the worst nurse I have ever had." Which response by the nurse is most assertive? a."I think you've had a hard day." b."I feel uncomfortable hearing that statement." c."I don't think you should say things like that. It is not right." d."I have been checking on you regularly. How can you say that?" - ans-b."I feel uncomfortable hearing that statement." OBJ:Demonstrate qualities, behaviors, and communication techniques of professional communication while interacting with patients. A smiling patient angrily states, "I will not cough and deep breathe." How will the nurse interpret this finding? a. The patient's denotative meaning is wrong. b. The patient's personal space was violated. c. The patient's affect is inappropriate. d. The patient's vocabulary is poor. - ans-c. The patient's affect is inappropriate. OBJ:Demonstrate qualities, behaviors, and communication techniques of professional communication while interacting with patients. The staff is having a hard time getting an older-adult patient to communicate. Which technique should the nurse suggest the staff use? a. Try changing topics often. b. Allow the patient to reminisce. c. Ask the patient for explanations. d. Involve only the patient in conversations - ans-b. Allow the patient to reminisce. OBJ:Engage in effective communication techniques for older patients. When making rounds, the nurse finds a patient who is not able to sleep because of surgery in the morning. Which therapeutic response is most appropriate? a."You will be okay. Your surgeon will talk to you in the morning." b."Why can't you sleep? You have the best surgeon in the hospital." c."Don't worry. The surgeon ordered a sleeping pill to help you sleep." d."It must be difficult not to know what the surgeon will find. What can I do to help?" - ans-d."It must be difficult not to know what the surgeon will find. What can I do to help?" OBJ:Demonstrate qualities, behaviors, and communication techniques of professional communication while interacting with patients. Which behavior indicates the nurse is using a process recording correctly to enhance communication with patients? a. Shows sympathy appropriately b. Uses automatic responses fluently c. Demonstrates passive remarks accurately d. Self-examines personal communication skills - ans-d. Self-examines personal communication skills OBJ: Identify opportunities to improve communication with patients while giving care. Which behaviors indicate the nurse is using critical thinking standards when communicating with patients? (Select all that apply.) a. Instills faith b. Uses humility c. Portrays self-confidence d. Exhibits supportiveness e. Demonstrates independent attitude - ans-b. Uses humility c. Portrays self-confidence e. Demonstrates independent attitude OBJ: Identify ways to apply critical thinking to the communication process. Which situation will cause the nurse to intervene and follow up on the nursing assistive personnel's (NAP) behavior? a. The nursing assistive personnel is calling the older-adult patient "honey." b. The nursing assistive personnel is facing the older-adult patient when talking. c. The nursing assistive personnel cleans the older-adult patient's glasses gently. d. The nursing assistive personnel allows time for the older-adult patient to respond. - ans-a. The nursing assistive personnel is calling the older-adult patient "honey." OBJ:Engage in effective communication techniques for older patients. Which types of nurses make the best communicators with patients? a. Those who learn effective psychomotor skills b. Those who develop critical thinking skills c. Those who like different kinds of people d. Those who maintain perceptual biases - ans-b. Those who develop critical thinking skills OBJ: Identify ways to apply critical thinking to the communication process. Explain the relationship between the infection chain and transmission of infection - ans-Infection chain cycle: infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, host -An infection will develop if this chain remains uninterrupted Give an example of preventing infection for each element of the infection chain - ans--infectious agent: washing hands with soap and water or an alcohol-based hand product -Reservoir: Keeping wounds in the light or turning the A/C at a temperature below 68*F -Portal of Exit: Standard, contact, and droplet precautions -Modes of Transmission: allows make sure food is fully cooked and safe to consume -Portal of Entry: keep wounds covered so there is no contact with bacteria -Host: do not take antibiotics frequently and do not smoke Identify the normal defenses of the body against infection. - ans--Normal floras do not usually cause disease when residing in their usual area of the body but help to maintain health -body system defenses: each organ system has defense mechanisms physiologically suited to their specific structure and function -inflammation: protective vascular reaction that delivers fluid, blood products, and nutrients to an area of injury which neutralizes and eliminates pathogens or dead tissues and establishes a means of repairing body cells and tissues. Discuss the events in the inflammatory response. - ans-acute inflammation is an immediate response to cellular injury. Rapid vasodilation occurs, allowing more blood near the location of the injury. increase in blood flow causes redness and localized warmth at site. May cause swelling of fluid, pain, temporary loss of function. WBCs arrive at spot and phagocytosis occurs causing an increase in WBCs and fever. Platelets and plasma proteins form a meshlike matrix at site of inflammation. Tissue also repairs itself by regrowing. Identify patients most at risk for infection. - ans-babies, older age, poor nutrition, stress, inherited conditions, chronic disease, and treatments or conditions that compromise the immune response increase susceptibility to infection, critical illnesses-diabetes mellitus or cancer, MS -IV catheters or indwelling urinary catheters -leukemia, AIDS, lymphoma, aplastic anemia, HIV-burns Describe the signs/symptoms of a localized infection and those of a systemic infection. - ans--Localized infections are most common in areas of skin or mucous membrane breakdown such as surgical and traumatic wounds, pressure ulcers, oral lesions, and abscesses. Symptoms include redness, warmth, and swelling, drainage from open lesions or wounds, tenderness, possible restriction of movement -Systemic infections cause more generalized symptoms than local infection. Symptoms include fever, fatigue, nausea/vomiting, malaise, swollen lymph nodes. Elevation in body temp can cause increased heart and respiratory rates and low BP. Explain conditions that promote the transmission of health care-associated infections. - ans-invasive procedures, antibiotic administration, presence of multidrug-resistant organisms, and breaks in infection prevention and control activities -surgical or traumatic wounds, urinary and respiratory tracts, and bloodstream Explain the difference between medical and surgical asepsis - ans--Medical asepsis techniques break the chain of infection (use even when there is no infection). Uses hand hygiene, barrier techniques, routine environmental cleaning -Surgical asepsis prevents contamination of an open wound, serves to isolate an operative area from the unsterile environment, and maintains a sterile field for surgery. Uses procedures to eliminate all microbes from an object or area. Used in OR, labor and delivery area, major diagnostic ways, and at patients bedside Explain the rationale for standard precautions - ans-Precautions set in place to protect the patient and provide protection for the health care worker. Applies to contact with blood, body fluid, nonitact skin, and mucous membranes To prevent control infection transmission. Apply to contact with blood, body fluid, non intact skin, and mucous membranes. Protect patients and provide protection for health care workers. ALWAYS BE USED! Perform proper procedures for hand hygiene - ans-vigorous, brief rubbing together of all surfaces of lathered hands, followed by rinsing under a stream of warm water for at least 15 seconds Explain how infection control measures differ in the home versus the hospital. - ans-In a hospital, a sterile processing department is responsible for disinfecting and sterilization of reusable items. Nurses in home health have to perform this themselves. -Cleaning: rinse in cold water, wash with soap and warm water, rinse thoroughly, use brush to remove dirt (open hinges), rinse in warm water, dry object and prepare for disinfection or sterilization, clean sink, brush, and gloves according. -disinfection eliminates many or all microbes except bacterial spores -sterilization eliminates or destroys all forms of microscopic life using steam, dry heat, hydrogen peroxide plasma, ethylene oxide (ETO) Define the nursing process and explain how nurses use the nursing process. - ans-Critical thinking process that professional nurses us to apply the nest available evidence to caregiving and promoting human functions and responses to heath and illness Match nursing actions with the step of the nursing process Assess Diagnose Planning Implementation Evaluate A) Gather information about the patient condition B) Identify the patient's problem C) Set goals of care and desired outcomes and identify appropriate nursing actions D) Perform the nursing actions identified in planning E) Determine if goals and expected outcomes are achieved - ans-Assess) A) Gather information about the patient condition Diagnose) B) Identify the patient's problem Planning) C) Set goals of care and desired outcomes and identify appropriate nursing actions Implementation) D) Perform the nursing actions identified in planning Evaluate) E) Determine if goals and expected outcomes are achieved Correctly identify subjective and objective data - ans-1. Subjective Data:-referred to as symptoms or covert data-what the patient tells you-can only be described & verified by person affected 2. Objective Data:--what nurse observes-detectable by observer-can be measured or tested against accepted standard-obtained by observation or physical examination-nurse obtains objective data to validate subject data Identify the necessary elements of correctly written goals - ans-1) Must be patient centered 2) Use SMART acronym Specific Measurable Attainable Realistic Timed Describe two different types and sources of data - ans-Data Documentation) Use clear, concise appropriate terminology Concept Mapping) Visual representation that allows toy to graphically show connections among a patient's many health problems Prioritize the nursing assessments in patients - ans-High) Emergent Intermediate) Non Life threatening Low) Affect patient's future well-being Identify interpendent, dependent, and interdependent interventions - ans-Nurse Initiated) Independent Actions that nurse initiates Health Care provider initiated) Dependent- Require an order from a physical or other heath care professional Collaborative) Interdependent-- Require combined knowledge, skill, and expertise of multiple heath care professionals Compare contrast standing and stat order - ans-Standing order) Standing orders are written protocols that authorize designated members of the health care team A stat order is used in a critical or life-threatening situation. Often, stat orders should be carried out right now, before any other task. Discuss the relationship of the nursing process to critical thinking - ans-Nursing Process is a systematic, rational method of planning and providing care which requires critical thinking skills to identify and treat actual or potential health problems and to promote wellness. It provides a framework for the nurses to be responsible and accountable. When working with an older adult who is hearing-impaired, the use of which techniques would improve communication? (Select all that apply.) 1. Check for needed adaptive equipment. 2. Exaggerate lip movements to help the patient lip read. 3. Give the patient time to respond to questions. 4. Keep communication short and to the point. 5. Communicate only through written information. - ans-1. Check for needed adaptive equipment. 3. Give the patient time to respond to questions. 4. Keep communication short and to the point. Nurses must communicate effectively with the health care team for which of the following reasons? (Select all that apply.) 1. Improve the nurse's status with the health team members 2. Reduce the risk of errors to the patient 3. Provide optimum level of patient care 4. Improve patient outcomes 5. Prevent issues that need to be reported to outside agencies - ans-2. Reduce the risk of errors to the patient 3. Provide optimum level of patient care 4. Improve patient outcomes A new nurse complains to her preceptor that she has no time for therapeutic communication with her patients. Which of the following is the best strategy to help the nurse find more time for this communication? 1. Include communication while performing tasks such as changing dressings and checking vital signs. 2. Ask the patient if you can talk during the last few minutes of visiting hours. 3. Ask Pastoral care to come back a little later in the day. 4. Remind the nurse to complete all her tasks and then set up remaining time for communication. - ans-1. Include communication while performing tasks such as changing dressings and checking vital signs. Motivational interviewing (MI) is a technique that applies understanding a patient's values and goals in helping the patient make behavior changes. What are other benefits of using MI techniques? (Select all that apply.) 1. Gaining an understanding of patient's motivations 2. Focusing on opportunities to avoid poor health choices 3. Recognizing patient's strengths and supporting their efforts 4. Providing assessment data that can be shared with families to promote change 5. Identifying differences in patient's health goals and current behaviors - ans-1. Gaining an understanding of patient's motivations 3. Recognizing patient's strengths and supporting their efforts 5. Identifying differences in patient's health goals and current behaviors A nurse is talking with a young-adult patient about the purpose of a new medication. The nurse says, "I want to be clear. Can you tell me in your words the purpose of this medicine?" This exchange 334is an example of which element of the transactional communication process? 1. Message 2. Obtaining feedback 3. Channel 4. Referent - ans-2. Obtaining feedback A patient who is Spanish-speaking does not appear to understand the nurse's information on wound care. Which action should the nurse take? 1. Arrange for a Spanish-speaking social worker to explain the procedure 2. Ask a fellow Spanish-speaking patient to help explain the procedure 3. Use a professional interpreter to provide wound care education in Spanish 4. Ask the patient to write down questions that he or she has for the nurse - ans-3. Use a professional interpreter to provide wound care education in Spanish A nurse prepares to contact a patient's physician about a change in the patient's condition. Put the following statements in the correct order using SBAR (Situation, Background, Assessment, and Recommendation) communication. 1. "She is a 53-year-old female who was admitted 2 days ago with pneumonia and was started on Levaquin at 5 PMyesterday. She complains of a poor appetite." 2. "The patient reported feeling very nauseated after her dose of Levaquin an hour ago." 3. "Would you like to make a change in antibiotics, or could we give her a nutritional supplement before her medication?" 4. "The patient started complaining of nausea yesterday evening and has vomited several times during the night." - ans-4 S. "The patient started complaining of nausea yesterday evening and has vomited several times during the night." 1. B "She is a 53-year-old female who was admitted 2 days ago with pneumonia and was started on Levaquin at 5 PMyesterday. She complains of a poor appetite." 2. A "The patient reported feeling very nauseated after her dose of Levaquin an hour ago." 3. R "Would you like to make a change in antibiotics, or could we give her a nutritional supplement before her medication?" A nurse is assigned to care for a patient for the first time and states, "I don't know a lot about your culture and want to learn how to better meet your health care needs." Which therapeutic communication technique did the nurse use in this situation? 1. Validation 2. Empathy 3. Sarcasm 4. Humility - ans-4. Humility A new nurse is experiencing lateral violence at work. Which steps could the nurse take to address this problem? 1. Challenge the nurses in a public forum to embarrass them and change their behavior 2. Talk with the department secretary and ask if this has been a problem for other nurses 3. Talk with the preceptor or manager and ask for assistance in handling this issue 4. Say nothing and hope things get better - ans-3. Talk with the preceptor or manager and ask for assistance in handling this issue A nurse has been gathering physical assessment data on a patient and is now listening to the patient's concerns. The nurse sets a goal of care that incorporates the patient's desire to make treatment decisions. This is an example of the nurse engaged in which phase of the nurse-patient relationship? 1. Working phase 2. Preinteraction phase 3. Termination phase 4. Orientation phase - ans-1. Working phase A patient is evaluated in the emergency department after causing an automobile accident while being under the influence of alcohol. While assessing the patient, which statement would be the most therapeutic? 1. "Why did you drive after you had been drinking?" 2. "We have multiple patients to see tonight as a result of this accident." 3. "Tell me what happened before, during, and after the automobile accident tonight." 4. "It will be okay. No one was seriously hurt in the accident." - ans-3. "Tell me what happened before, during, and after the automobile accident tonight." A nursing student is reviewing a process recording with the instructor. The student engaged the patient in a discussion about availability of family members to provide support at home once the patient is discharged. The student reviews with the instructor whether the comments used encouraged openness and allowed the patient to "tell his story." This is an example of which step of the nursing process? 1. Planning 2. Assessment 3. Intervention 4. Evaluation - ans-4. Evaluation Which strategies should a nurse use to facilitate a safe transition of care during a patient's transfer from the hospital to a skilled nursing facility? (Select all that apply.) 1. Collaboration between staff members from sending and receiving departments 2. Requiring that the patient visit the facility before a transfer is arranged 3. Using a standardized transfer policy and transfer tool 4. Arranging all patient transfers during the same time each day 5. Relying on family members to share information with the new facility - ans-1. Collaboration between staff members from sending and receiving departments 3. Using a standardized transfer policy and transfer tool The nurse uses silence as a therapeutic communication technique. What is the purpose of the nurse's silence? (Select all that apply.) 1. Prevent the nurse from saying the wrong thing 2. Prompt the patient to talk when he or she is ready 3. Allow the patient time to think and gain insight 4. Allow time for the patient to drift off to sleep 5. Determine if the patient would prefer to talk with another staff member - ans-2. Prompt the patient to talk when he or she is ready 3. Allow the patient time to think and gain insight What is the most effective way to control transmission of infection? 1. Isolation precautions 2. Identifying the infectious agent 3. Hand hygiene practices 4. Vaccinations - ans-3. Hand hygiene practices A patient who has been isolated for Clostridium difficile (C. difficile) asks you to explain what he should know about this organism. What is the most appropriate information to include in patient teaching? (Select all that apply.) 1. The organism is usually transmitted through the fecal-oral route. 2. Hands should always be cleaned with soap and water versus alcohol-based hand sanitizer. 3. Everyone coming into the room must be wearing a gown and gloves. 4. While the patient is in contact precautions, he cannot leave the room. 5. C. difficile dies quickly once outside the body - ans-1. The organism is usually transmitted through the fecal-oral route. 2. Hands should always be cleaned with soap and water versus alcohol-based hand sanitizer. 3. Everyone coming into the room must be wearing a gown and gloves. Your assigned patient has a leg ulcer that has a dressing on it. During your assessment you find that the dressing is saturated with purulent drainage. Which action would be best on your part? 1. Reinforce dressing with a clean, dry dressing and call the health care provider. 2. Remove wet dressing and apply new dressing using sterile procedure. 3. Put on gloves before removing the old dressing; then obtain a wound culture. 4. Remove saturated dressing with gloves, remove gloves, then perform hand hygiene and apply new gloves before putting on a clean dressing. - ans-4. Remove saturated dressing with gloves, remove gloves, then perform hand hygiene and apply new gloves before putting on a clean dressing. A patient is diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. Which type of isolation precaution is most appropriate for this patient? 1. Reverse isolation 2. Droplet precautions 3. Standard precautions 4. Contact precautions - ans-2. Droplet precautions A family member is providing care to a loved one who has an infected leg wound. What should the nurse instruct the family member to do after providing care and handling contaminated equipment or organic material? 1. Wear gloves before eating or handling food. 2. Place any soiled materials into a bag and double bag it. 3. Have the family member check with the health care provider about need for immunization. 4. Perform hand hygiene after care and/or handling contaminated equipment or material. - ans-4. Perform hand hygiene after care and/or handling contaminated equipment or material. A patient is isolated for pulmonary tuberculosis. The nurse notes that the patient seems to be angry, but he knows that this is a normal response to isolation. Which is the best intervention? 1. Provide a dark, quiet room to calm the patient. 2. Reduce the level of precautions to keep the patient from becoming angry. 3. Explain the reasons for isolation procedures and provide meaningful stimulation. 4. Limit family and other caregiver visits to reduce the risk of spreading the infection. - ans-3. Explain the reasons for isolation procedures and provide meaningful stimulation. When should a nurse wear a mask? (Select all that apply.) 1. The patient's dental hygiene is poor. 2. The nurse is assisting with an aerosolizing respiratory procedure such as suctioning. 3. The patient has acquired immunodeficiency syndrome (AIDS) and a congested cough. 4. The patient is in droplet precautions. 5. The nurse is assisting a health care provider in the insertion of a central line catheter. - ans-2. The nurse is assisting with an aerosolizing respiratory procedure such as suctioning. 4. The patient is in droplet precautions. 5. The nurse is assisting a health care provider in the insertion of a central line catheter. Which type of personal protective equipment are staff required to wear when caring for a pediatric patient who is placed into airborne precautions for confirmed chickenpox/herpes zoster? (Select all that apply.) 1. Disposable gown 2. N 95 respirator mask 3. Face shield or goggles 4. Surgical mask 5. Gloves - ans-1. Disposable gown 2. N 95 respirator mask 5. Gloves The infection control nurse has asked the staff to work on reducing the number of iatrogenic infections on the unit. Which of the following actions on your part would contribute to reducing health care-acquired infections? (Select all that apply.) 1. Teaching correct handwashing to assigned patients 2. Using correct procedures in starting and caring for an intravenous infusion 3. Providing perineal care to a patient with an indwelling urinary catheter 4. Isolating a patient who has just been diagnosed as having tuberculosis 5. Decreasing a patient's environmental stimuli to decrease nausea - ans-1. Teaching correct handwashing to assigned patients 2. Using correct procedures in starting and caring for an intravenous infusion 3. Providing perineal care to a patient with an indwelling urinary catheter Which of the following actions by the nurse comply with core principles of surgical asepsis? (Select all that apply.) 1. Set up sterile field before patient and other staff come to the operating suite. 2. Keep the sterile field in view at all times. 3. Consider the outer 2.5 cm (1 inch) of the sterile field as contaminated. 4. Only health care personnel within the sterile field must wear personal protective equipment. 5. The sterile gown must be put on before the surgical scrub is performed. - ans-2. Keep the sterile field in view at all times. 3. Consider the outer 2.5 cm (1 inch) of the sterile field as contaminated. A patient has an indwelling urinary catheter. Why does an indwelling urinary catheter present a risk for urinary tract infection? (Select all that apply.) 1. It allows migration of organisms into the bladder. 2. The insertion procedure is not done under sterile conditions. 3. It obstructs the normal flushing action of urine flow. 4. It keeps an incontinent patient's skin dry. 5. The outer surface of the catheter is not considered sterile. - ans-1. It allows migration of organisms into the bladder. 3. It obstructs the normal flushing action of urine flow. Put the following ste