Which one of the following indicates that the nurse is using ...

[fbq8i]

Which one of the following indicates that the nurse is using surgical aseptic technique?
 
  a. Inserting an intravenous catheter
  b. Placing soiled linen in moisture-resistant bags
  c. Disposing of syringes in puncture-proof containers
  d. Washing hands before changing a dressing

Question 2

A 61-year-old patient recently had left-sided paralysis from a cerebrovascular accident (CVA, stroke). In planning care for this patient, the nurse implements which one of the following as an appropriate intervention?
 
  a. Encouraging an even gait when walking in place
  b. Assessing the extremities for unilateral swelling and muscle atrophy
  c. Encouraging holding the breath frequently to hyperinflate the lungs
  d. Teaching the use of a two-point crutch technique for ambulation

[aadams68]

Answer to Question 1

A
Surgical asepsis should be used during procedures that require intentional perforation of the cli-ent's skin, such as with the insertion of IV catheters.
The nurse is using medical aseptic technique when placing soiled linen in moisture-resistant bags.
The nurse is using medical aseptic technique when disposing of syringes in puncture-proof con-tainers.
The nurse is using medical aseptic technique when washing hands before changing a dressing.

Answer to Question 2

B

Feedback
A The patient who has suffered a CVA with left-sided paralysis may not be capable of an even gait.
B Because edema moves to dependent body regions, assessment of the immobilized patient should include the sacrum, legs, and feet. Unilateral increases in calf diameter can be an early indication of thrombosis.
C Having the patient hold his or her breath frequently is not an appropriate nursing intervention. To prevent stasis of pulmonary secretions, the patient's position should be changed every two hours, and fluids should be increased to 2000 mL, if not contraindicated. The patient should deep breathe and cough every one to two hours to promote chest expansion.
D Two-point crutch technique would not be appropriate for the patient with left-sided paralysis. The patient would most likely ambulate safely with a walker or a cane. If crutches are used, the patient should use a three-point support.