NR-224 Fundamentals – Skills - Set 2 - Part 1

Correct Answer: Stop the nurse and require new gloves

Moving from a contaminated site to a clean site on the same client requires glove removal, hand hygiene and fresh gloves. Continuing with the same gloves carries stool organisms directly into a healing surgical incision. Option b is incorrect because the harm happens the moment the dressing touches the wound. Feedback afterward cannot undo an inoculated incision, so the preceptor intervenes before the contaminated gloves reach clean tissue. Option c is incorrect because documentation addresses the record rather than the break in technique. Charting both procedures accurately would leave the incision exposed to colonic flora and would simply create a written account of the error. Option d is incorrect because a gown protects the nurse's uniform, not the client's wound. Adding one while the same soiled gloves stay on leaves the actual route of transfer, the hands, completely untouched.

Correct Answer: An eighty-year-old on chemotherapy with a catheter

Risk factors stack. An extreme of age brings immunosenescence, chemotherapy produces neutropenia, and an indwelling catheter is a standing portal of entry. Three compounding factors outweigh any single serious-sounding diagnosis. Option a is incorrect because pneumonia with diabetes carries real risk, yet this client has intact marrow, an intact immune response and no invasive device. Middle age also preserves the physiologic reserve that infection consumes. Option b is incorrect because a surgical incision does breach the skin barrier, but that is one factor operating in a client whose immune system and age-related defenses are working normally. One risk factor does not outrank three. Option d is incorrect because a healing wound signals that the inflammatory and repair processes are functioning. Youth, an intact immune system and the absence of any device make this the lowest-risk client of the four.

Correct Answer: Sterilization by steam under pressure

An item entering sterile tissue is a critical item and must be sterilized. Steam under pressure in an autoclave destroys all microorganisms, including bacterial spores, and is the preferred method for heat-tolerant instruments. Option b is incorrect because high-level disinfection is the standard for semi-critical items such as endoscopes and oral thermometers. It tolerates a few surviving bacterial spores, and tissue beneath the skin has no defense against them at all. Option c is incorrect because a germicidal wipe cannot reach the hinges, box locks and lumens of an instrument set. Even on flat surfaces it kills vegetative organisms while leaving spores intact. Option d is incorrect because cleaning removes soil rather than killing organisms. It is the mandatory first step before any instrument is sterilized, since organic material shields microbes, but on its own it leaves the set unsterile.

Correct Answer: Placing the drainage bag on the floor briefly

A drainage bag set on the floor picks up organisms from the most contaminated surface in the room and carries them back toward the closed system. The bag stays off the floor and below the level of the bladder. Option a is incorrect because emptying into a clean container assigned to that client is correct practice and keeps the collection system closed. Assistive personnel may perform this task and record the output. Option b is incorrect because routine perineal hygiene with plain soap and water is exactly what current guidance directs for a client with a catheter. Antiseptics at the meatus would be the error, not ordinary washing. Option d is incorrect because anchoring the tubing prevents traction on the urethra and the movement that lets organisms travel along the catheter. Securing the device is a recommended step rather than one needing correction.

Correct Answer: Gown and gloves before crossing the threshold

Contact precautions call for gown and gloves for every interaction that may involve touching the client or the surfaces around the bed. Both are applied before entry and removed before leaving the room. Option b is incorrect because a mask and goggles guard the facial mucous membranes against splash and against respiratory droplets. Resistant organisms in a wound travel by hands and equipment, not through the air. Option c is incorrect because a respirator belongs to airborne precautions, where particles stay suspended and must be filtered at the face. Nothing about a wound colonized with resistant bacteria calls for that barrier. Option d is incorrect because the gown is not reserved for anticipated splash under this category. It is required routinely, since clothing contacts linens, rails and the over-bed table during ordinary bedside care.

Correct Answer: The gloves, peeled off and turned inside out

Gloves carry the heaviest contamination of any item worn, so they come off first, before they can transfer organisms to the hands, the face, or the other equipment still being worn. Option a is incorrect because the gown is removed third, after the gloves and eye protection. Untying it with contaminated gloves still on the hands would smear organisms across the ties and the neckline. Option b is incorrect because the mask guards the airway and is therefore the last barrier taken off, once every other item is gone. Removing it early exposes the nose and mouth. Option c is incorrect because eye protection comes off second in the sequence. Handling the headband while gloved would carry wound drainage from the glove surface directly onto a piece worn against the face.

Correct Answer: Standard precautions apply to every client in every setting

Standard precautions are the baseline for all care because infectious status is often unknown during incubation, carriage, or before cultures result. Every client's blood and body substances are treated as potentially infectious regardless of diagnosis. Option a is incorrect because waiting for a culture leaves the nurse and the next client unprotected during the days a specimen takes to grow. Precautions must already be in place before any organism is named. Option b is incorrect because transmission-based precautions are a second tier layered on top of the standard set, never a substitute for it. A client on contact precautions still receives every standard element. Option d is incorrect because the rule reaches beyond what the eye can see. Non-intact skin, mucous membranes, and secretions with no visible blood all fall under the same barrier requirement.

Correct Answer: Changing a central venous catheter dressing

A central line enters the vascular system, so its dressing change is performed with sterile gloves, a mask and a sterile field. Any procedure that crosses the skin into sterile tissue demands surgical asepsis. Option b is incorrect because the gastrointestinal tract is not a sterile cavity. Nasogastric tube insertion is a clean procedure done with clean gloves and water-soluble lubricant, so the standard never rises above medical asepsis. Option c is incorrect because emptying a drainage bag touches only the outside of a closed system. Catheter insertion is sterile, but routine catheter care such as emptying the bag is clean technique with clean gloves. Option d is incorrect because a patch is placed on intact skin, which remains an effective barrier. Clean gloves are worn here to keep the nurse from absorbing the medication, not to protect a sterile site.

Correct Answer: Indirect contact through a contaminated object

An uncleaned stethoscope is a fomite, an inanimate object that carries organisms from one client to the next. Transfer through an intermediate item, rather than skin to skin, defines indirect contact. Option a is incorrect because a vehicle is a single common source such as food, water, blood products or a medication vial that reaches many people at once. A stethoscope moves between two clients. Option b is incorrect because droplets require respiratory particles expelled by coughing, sneezing, talking or suctioning, and they fall out of the air quickly. Nothing in this scenario involves the respiratory route. Option c is incorrect because direct contact needs physical transfer between an infected person and a susceptible host, as with scabies or impetigo. These two clients never touched one another.

Correct Answer: Remove the requisition from the specimen compartment

The requisition stays outside the specimen compartment so paperwork does not contact the container or become soiled. The container itself carries the label, and the outside of the transport bag must stay clean. Option a is incorrect because identification belongs on the container that holds the sample, not on a bag that will be opened and discarded. Labeling the bag risks a specimen reaching the laboratory unidentified. Option b is incorrect because a second bag is added only when the outside of the first becomes soiled or could be punctured. Routine double-bagging wastes supplies and does not fix the misplaced paperwork. Option d is incorrect because an unlabeled specimen is a patient safety event in its own right. The laboratory would reject it, the client would need a second painful collection, and treatment would be delayed.

Correct Answer: Assess readiness to extubate every day

Every additional day of intubation raises pneumonia risk, so a daily assessment of readiness to extubate shortens exposure and removes the device that bypasses the airway defenses. Extubating sooner prevents more pneumonia than any cleaning measure. Option a is incorrect because scheduled circuit changes have not been shown to lower pneumonia rates and each disconnection creates an opportunity for contamination. Circuits are changed when visibly soiled or malfunctioning, not on a calendar. Option b is incorrect because deep sedation suppresses the cough, prolongs ventilation and delays the very extubation that protects the client. Minimizing sedation with daily awakening trials is what current prevention bundles direct. Option c is incorrect because instilling saline pushes organisms from the tube deeper into the lower airway and lowers oxygen saturation during the procedure. The practice was abandoned once its harms became clear.

Correct Answer: The expected inflammatory response to surgical injury

Redness, warmth, tenderness and serosanguineous drainage on the first day after surgery are the normal vascular response to the surgical wound. Inflammation peaks in the first three days and then settles, and no systemic findings are present. Option a is incorrect because a surgical site infection typically declares itself after the third day, with purulent drainage, increasing pain and fever. None of those discriminators is present here, so culturing an ordinary healing incision is premature. Option c is incorrect because dehiscence describes wound edges that pull apart and separate, often with a sudden gush of serosanguineous fluid. This incision is intact, and redness alone never establishes that the layers have failed. Option d is incorrect because adhesive reactions produce itching and a rash shaped like the tape or dressing border, not warmth and tenderness centered on the suture line. The distribution of these findings points to the wound itself.

Correct Answer: "My bare hand touches only the folded inside of the cuff."

Open gloving rests on a single rule. The bare hand may touch only the folded inside of the cuff, and the sterile gloved hand may touch only the outside. Every step protects that boundary. Option a is incorrect because fit is adjusted only after both gloves are on. Fiddling with a partly seated glove while one hand is still bare invites contact between skin and the sterile outer surface. Option b is incorrect because it reverses the rule. The outside of a sterile glove is the surface that will touch the client, so bare skin contacting it makes the glove unusable and a new pair is needed. Option d is incorrect because sterile items are held above waist level and in view. Working below the table puts the gloves outside the nurse's field of vision, and anything held there counts as contaminated.

Correct Answer: "Your child may be incubating the virus and needs watching."

Incubation is the interval between the pathogen entering the host and the first symptom appearing. The child feels well because too few organisms are present so far, but exposure has occurred and illness may follow. Option b is incorrect because the absence of a rash proves only that the specific findings have not yet appeared. Many communicable diseases are already transmissible late in incubation, before anything visible develops. Option c is incorrect because the illness stage requires findings specific to the disease, and the vesicular rash of varicella has not appeared. Naming that stage now would misstate where the child actually is. Option d is incorrect because varicella travels on airborne particles and needs only a small infectious dose. A single afternoon of close play is more than enough exposure to transmit the virus.

Correct Answer: "I shut the faucet off with a dry paper towel."

The faucet handle is contaminated, and touching it with clean bare hands recontaminates them. Turning the water off through a dry paper towel keeps the barrier intact and completes handwashing correctly. Option a is incorrect because that position belongs to the surgical scrub. For routine handwashing the hands are held lower than the elbows so water carries organisms from the forearms down off the fingertips. Option b is incorrect because the handle was touched by soiled hands before the wash began. Gripping it again undoes the whole procedure, and this is one of the most common findings on hand hygiene audits. Option c is incorrect because water temperature has no effect on the number of organisms removed. Hot water dries and cracks the skin, creating breaks that harbor bacteria, so warm running water is used instead.

Correct Answer: Negative air pressure relative to the corridor

Tuberculosis spreads by droplet nuclei that stay suspended in air, so the client needs an airborne infection isolation room. Negative pressure draws air into the room and prevents contaminated air from reaching the corridor. Option a is incorrect because positive pressure pushes room air outward into the hallway. Used for a client shedding tubercle bacilli, it would drive infectious air toward staff and other clients rather than contain it. Option c is incorrect because ordinary ventilation with an open door is what droplet precautions permit. Large droplets settle quickly, but tubercle bacilli ride air currents out of an unsealed room and down the hall. Option d is incorrect because filtered incoming air describes the protective environment built for a stem cell transplant recipient. That design shields a vulnerable client and does nothing to trap organisms leaving the room.

Correct Answer: Disinfecting shared equipment between two clients

Cleaning and disinfecting shared equipment is a standardized task with a predictable outcome, and assistive personnel are trained and permitted to do it. The nurse still verifies competence, gives clear direction and follows up on the result. Option a is incorrect because every sterile procedure stays with the nurse. A sterile dressing change requires setting up and protecting a sterile field, and it includes assessing the wound, which is nursing judgment. Option b is incorrect because teaching belongs to the nurse alone. Assistive personnel may reinforce what has already been taught and may remind a visitor to use the gown, but they cannot deliver the instruction. Option d is incorrect because assessment is never delegated. An assistant who notices redness or drainage reports the observation, while deciding what that finding means and how to act on it remains with the nurse.

Correct Answer: Systemic infection requiring prompt provider notification

Fever above one hundred point four degrees, tachycardia and generalized aching are whole body findings, which means the organism has spread beyond the ulcer. Any systemic sign moves the classification to systemic regardless of how the wound looks. Option b is incorrect because a localized infection stays at one site and produces redness, warmth, swelling and purulent drainage there alone. This client has fever, tachycardia and diffuse aching, which no longer fit a single site. Option c is incorrect because ordinary inflammation after injury peaks locally within the first few days and produces little or no systemic disturbance. A rising temperature paired with tachycardia points to organisms circulating, not to uncomplicated tissue repair. Option d is incorrect because colonization means organisms are present and multiplying while the host mounts no response at all. Symptoms, fever and a raised pulse are precisely the host response that separates true infection from simple colonization.

Correct Answer: Request an order to remove the catheter

Duration of catheterization is the single greatest risk factor for catheter-associated urinary tract infection. Removing the device eliminates the portal of entry completely, which no amount of cleaning or maintenance can achieve. Option a is incorrect because meatal care is performed with soap and water, not antiseptics, which irritate tissue and disturb protective flora. Cleaning also leaves the catheter itself in place as an open pathway. Option b is incorrect because routine irrigation breaks the closed drainage system and introduces organisms straight into the bladder. Irrigation is reserved for an ordered indication such as obstruction, never for infection prevention. Option c is incorrect because opening the system to swap bags on a schedule raises rather than lowers risk. Bags are changed when soiled, damaged or leaking, and the catheter would still remain.

Correct Answer: Wear a gown and gloves and remove them inside

Visitors follow the same contact barriers as staff. Gown and gloves are applied before entry and removed inside the room, followed by hand hygiene, which keeps the organism from traveling out on clothing or hands. Option b is incorrect because a respirator answers a threat that is not present here. Resistant organisms on skin, wounds and bedside surfaces move by touch, so the barrier that matters covers the hands and clothing. Option c is incorrect because forbidding touch adds to the loneliness that isolation already imposes. A gowned and gloved visitor may hold a hand and sit close, and that contact is part of the care plan. Option d is incorrect because bathing at home is not the control measure. Protection comes from barriers worn during the visit and from hand hygiene at the doorway, both of which happen before the spouse leaves.