Test 21 Rationales: Comprehensive Nursing Fundamentals: Sterile Technique, OSA, Wound Healing, and Patient Care

When are sterile gloves donned for urinary catheter insertion?

After opening the package; the outside packaging is nonsterile.

How far is an indwelling catheter advanced after urine appears?

Another 5 cm (2 inches), then inflate the balloon to help ensure correct placement.

What should be done if a urinary catheter is accidentally inserted into the vagina?

Leave it as a landmark and reattempt with a new catheter.

Why should the catheter balloon not be inflated before insertion?

It can cause small tears and alter balloon shape, increasing infection and urethral trauma risk.

How is the female urinary meatus cleansed for catheter insertion?

Spread the labia with the nondominant hand and cleanse downward from the meatus, using a new wipe each time.

How is the male urinary meatus cleansed for catheter insertion?

Clean in circular patterns from the urethral meatus toward the base, using new wipes each time.

What breathing instruction helps during catheter insertion?

Deep breathe and insert during exhalation.

How much catheter tip is lubricated for females and males?

Female: 2-5 cm (1-2 inches). Male: 12-17 cm (5-7 inches).

Where are catheter tubing and the drainage bag positioned?

Secure tubing to the leg and keep the bag below the bladder.

What causes obstructive sleep apnea (OSA)?

Recurrent upper airway obstruction during sleep as pharyngeal and oral muscles relax.

Why does a client with OSA awaken repeatedly?

Obstructed airflow causes hypoxia, which awakens the client to breathe.

What are the emphasized risk factors for OSA?

Obesity, large neck circumference, menopause, and anatomical airway abnormalities.

Which obesity measurements increase OSA risk?

BMI above 30 and neck circumference above 16 inches (40.6 cm).

Why can menopause increase OSA risk?

Lower estrogen and progesterone levels allow greater airway muscle relaxation.

How does central apnea differ from OSA?

Central apnea involves brainstem injury disrupting automatic signals to breathing muscles; OSA involves physical upper airway obstruction.

Which anatomical abnormalities can contribute to OSA?

Deviated nasal septum, nasal polyps, narrow lower jaw, and enlarged tonsils.

What may touch a sterile object or sterile field?

Only other sterile objects; contact with clean or contaminated objects contaminates it.

Where must sterile objects and hands remain?

In view and above waist level; anything below the waist is considered nonsterile.

Which part of a sterile field is contaminated?

The outer 1 inch (2.5 cm) border.

Which flap is opened first when setting up a sterile kit?

The flap farthest from the body.

Why does wet sterile packaging require discarding the contents?

Moisture allows microorganisms to travel by capillary action and contaminate the contents.

How is a surgical hand scrub performed?

Scrub from hands toward elbows while keeping hands above elbows.

Why avoid prolonged air exposure of a sterile field?

Prolonged exposure and excess air movement contaminate the field.

How is a female clean-catch urine specimen collected?

Spread labia, cleanse front to back, keep labia spread, and collect midstream.

Why collect clean-catch urine midstream?

The initial urine flushes bacteria near the urethral opening.

How much clean-catch urine is requested?

About 10 mL; remove the cup before urination ends.

Why avoid circular cleansing for female clean-catch collection?

It may introduce bacteria; cleanse front to back.

Why can infection be hard to recognize in an immunosuppressed transplant client?

Typical signs may be absent; low-grade fever may be the only indicator.

What temperature should be reported for the protected transplant client?

Above 100.0 F (37.8 C).

What room airflow is used for protective isolation?

A private positive-airflow room with HEPA filtration.

What visitor and transport precautions support protective isolation?

Screen visitors for infection and restrict ill visitors.

How are equipment and unnecessary catheters handled in protective isolation?

Keep frequently used equipment in the room and avoid sharing.

How do lifting devices prevent pressure injuries?

They reduce shearing and friction caused by dragging skin across surfaces.

What seated pressure-relief instruction is given for paraplegia?

Shift weight every 15-30 minutes.

Why avoid donut-shaped cushions for pressure relief?

They concentrate pressure at the edges and can cause capillary damage.

How are heels protected from pressure injury?

Float or offload heels with a pillow or heel-lift boots.

What exercise supports pressure-injury prevention in paraplegia?

Range-of-motion exercises prevent contractures.

What head-of-bed limit is given in pressure-injury prevention?

Keep it at or below 30 degrees.

What nutrition measures support skin integrity and repair?

Monitor weight and prealbumin; provide adequate protein, vitamin C, and iron.

What does a Braden score of 12 or less indicate?

High pressure-injury risk.

What protects skin during incontinence care?

Monitor for maceration and apply a barrier cream.

Should reddened pressure areas be massaged?

No, massage damages capillaries.

Which support surface helps a client at high pressure-injury risk?

A pressure redistribution mattress.

Why can broad-spectrum antibiotics lead to C. difficile infection?

They disrupt normal intestinal flora.

What initial actions are supported for suspected C. difficile?

Send a stool specimen for confirmation and initiate contact precautions.

What should be monitored with large-volume C. difficile diarrhea?

Serum potassium and intake and output.

Why avoid loperamide with C. difficile?

It slows bowel movements and increases exposure to the toxin.

How can positioning and airflow relieve end-of-life dyspnea?

Elevate the head to improve chest expansion.

How does morphine help end-of-life labored breathing?

It slows respirations and improves labored breathing.

What oral care and warming measures support end-of-life comfort?

Provide mouth care every 2-4 hours and extra blankets; avoid electric blankets.

How should food be offered at the end of life?

Focus on pleasurable tastes and client preference; do not force food.

What flow range and use are listed for nasal cannula?

1-6 L/min for mild to moderate hypoxemia or long-term oxygen therapy.

What flow range and use are listed for a simple face mask?

5-10 L/min for short-term oxygen therapy or acute respiratory distress.

What flow range is listed for partial and nonrebreather masks?

10-15 L/min with a reservoir bag for high oxygen delivery in acute severe hypoxemia.

What must be checked on a nonrebreather reservoir bag?

It should remain partially inflated during inspiration.

Why must Venturi mask air-intake ports remain unobstructed?

They mix oxygen with room air to deliver a precise concentration.

What is the main advantage of a Venturi mask?

Precise oxygen concentration for a specific FiO2 requirement.

What does high-flow nasal cannula deliver?

Heated, humidified gas at 20-60 L/min; FiO2 up to 100%.

When does the nasal cannula rationale identify humidification as helpful?

At higher flow rates, at least 4 L/min.

What causes dumping syndrome after gastric surgery?

Rapid emptying of stomach contents into the small intestine.

Which post-meal findings suggest dumping syndrome?

Dizziness, diaphoresis, syncope, tachycardia, pallor, nausea, or diarrhea.

Why are fever or decreased hemoglobin not explained by dumping syndrome?

Fever suggests infection or an anastomotic leak; decreased hemoglobin suggests hemorrhage.

What meal pattern helps reduce dumping after gastrectomy?

About six small meals daily; high protein and fat, low to moderate carbohydrates.

When should fluids be taken after gastrectomy?

Avoid fluids during meals; drink 30-45 minutes before or after eating.

What is a mechanical soft diet used for?

Difficulty chewing or swallowing.

Which mechanical soft examples are supported?

Flaked fish, pudding, bananas, cooked vegetables, rice, pasta, scrambled eggs, and cottage cheese.

Why are celery sticks and fried eggs on toast poor choices in the dysphagia scenario?

Raw vegetables are hard and crunchy; toast requires more chewing.

How does a three-point crutch gait proceed for non-weight-bearing status?

Advance both crutches and the injured leg, then advance the unaffected leg.

How are crutches fitted and body weight supported?

Pads sit 2-3 fingerbreadths below the axilla; elbows flex 15-30 degrees.

What is the sequence when descending stairs with crutches?

Lower the crutch and injured leg first, then the strong leg.

What is primary intention wound healing?

Wound edges are approximated with sutures; healing is quick with minimal scarring.

What is secondary intention wound healing?

Edges remain open and the wound fills from the bottom up.

What is tertiary or delayed primary intention healing?

The wound is initially left open for drainage and cleaning.

What are the two main uses of an NG tube?

Deliver enteral nutrition or remove gastric contents.

What position and swallowing instructions help NG insertion?

Use high-Fowler position; have the client tuck chin and swallow repeatedly.

How is NG insertion length measured?

From nose to earlobe, then to the xiphoid process.

What if NG insertion meets resistance or causes respiratory distress?

Stop insertion, remove the tube, and start over.

What confirms initial NG placement before use?

An X-ray confirming placement in the stomach.

How is NG placement checked before subsequent use?

Aspirate gastric contents or test the aspirate pH.

Where is a sterile urine culture specimen collected from an indwelling catheter?

The disinfected sampling port.

What catheter clamping step precedes sterile urine sampling?

Clamp below the sampling port for 10-15 minutes.

Why avoid clamping a catheter for an hour to collect a specimen?

Prolonged obstruction increases infection risk.

Why avoid flushing the catheter before collecting a urine specimen?

Irrigation fluid can dilute the sample.

How is a catheter urine specimen handled after collection?

Label and send immediately; refrigerate or deliver within 20 minutes.

When and in what position should sputum be collected?

In the morning, with the client in semi-Fowler or high-Fowler position.

What mouth care is used before sputum collection?

Rinse with water; avoid mouthwash and toothpaste.

Can sputum be collected from an intubated client?

Yes, use suction if the client cannot cough.

What precautions apply to sputum collection for suspected tuberculosis?

Airborne precautions, including a negative-pressure airflow room.

Why is sputum collected for culture and sensitivity?

To identify pathogens and determine antibiotic sensitivity.

What perineal care does the CAUTI rationale recommend?

Soap and water twice per shift.

How often and how fully should a catheter drainage bag be emptied?

Empty regularly, at least once per shift.

Where should the catheter drainage bag stay during transport?

Below bladder level.

What hand protection is needed when handling catheter tubing or the collection bag?

Wear gloves to prevent contamination.

Which foods does a vegan diet exclude?

All animal-based products.

Which nutrient teaching is emphasized for vegan clients?

Regular vitamin B12 supplementation and fortified plant foods.

How can vegan clients improve iron absorption?

Pair iron-rich plant foods with vitamin C-rich foods.