NUR 336 MIDTERM More Questions With Complete
Solutions
Abdominal auscultation Correct Answers Auscultate bowel
sounds using diaphragm in 4 quadrants
==> Bowel sounds present all 4 quadrants (+BSx4)
AUSCULTATE BEFORE PALPATION
active listening Correct Answers sit facing client, observe with
an open posture, lean toward client, establish intermittent eye
contact, relax
application of sterile gloves Correct Answers 1) To perform
sterile gloving, first select the correct size and type of gloves.
Also examine the package to ensure that it is dry and intact.
2) Then after performing hand hygiene, open the sterile glove
package by carefully separating and peeling open its sides. Be
careful not to accidentally open the inner sterile wrapper.
3) Grasp the inner glove wrapper, and lay it on a clean, dry, flat
surface at waist level. Then open the wrapper, keeping the
gloves on its inside surface.
4) Open the sterile wrapper then open the inner flaps starting
with the upper, then the lower and finally the sides touching
only the tip of the paper maintaining one inch border.
5) Identify the right and left gloves, which have about 5-inch-
wide cuffs. Plan to glove your dominant hand first.
6) Using the thumb and first two fingers of your nondominant
hand, grasp the folded edge of the cuff on the dominant hand's
glove. Touch only the glove's inner surface.
,7) Carefully pull the glove over dominant hand, keeping the cuff
folded and making sure it doesn't roll up your wrist. Carefully
work thumb and fingers into the correct spaces.
8) With gloved dominant hand, slip fingers inside the second
glove's cuff.
9) Carefully pull the second glove over the fingers of
nondominant hand, making sure no part of the gloved hand
touches the exposed hand while adjusting cuff on wrist.
10) If need to adjust the gloves, at this stage, maintain sterile-to-
sterile contact.
11) Interlock fingers and hold hands away from body, above
waist level and within line of vision, until the procedure begins.
areas of safety (who and what to keep safe): Correct Answers
health professional, client, environment
assessment of allergies Correct Answers What are you allergic
to?
What happens when you are exposed to that allergen?
Are you allergic to anything else?
auscultation Correct Answers Auscultation involves listening
for various lung, heart, and bowel sounds with a stethoscope
breaking the chain of infection: host Correct Answers Reduce
susceptibility to infection.
Provide adequate nutrition.
Ensure adequate rest.
Promote body defenses against infection.
Provide immunization
, breaking the chain of infection: infectious agent Correct
Answers clean contaminated objects
clean, disinfect, and sterilize
breaking the chain of infection: portal of entry Correct Answers
Skin and mucosa
Maintain skin and mucous membrane integrity; lubricate skin,
offer frequent hygiene, turn and position.
Cover wounds as needed.
Clean wound sites thoroughly.
Dispose of used needles in puncture-proof container.
Urinary
Keep all drainage systems closed and intact, maintaining
downward flow.
breaking the chain of infection: portal of exit Correct Answers
Respiratory
Avoid talking, sneezing, or coughing directly over wound or
sterile dressing field.
Cover nose and mouth when sneezing or coughing.
Wear mask if suffering respiratory tract infection.
Urine, feces, emesis, and blood
Wear clean gloves when handling blood and body fluids.
Wear gowns and eyewear if there is a chance of splashing fluids.
Handle all laboratory specimens as if infectious
breaking the chain of infection: reservoir Correct Answers
Perform hand hygiene before and after patient contact with
appropriate antiseptic (e.g., chlorhexidine) or soap and water.
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