Sterile Technique And Asepsis
Help Questions
NCLEX-PN › Sterile Technique And Asepsis
Which action should the nurse take next?
Discard the contaminated supplies and set up a new sterile field.
Wipe the bedside table with an alcohol swab and reuse the unopened supplies.
Cover the current sterile field with a sterile towel and continue the procedure.
Proceed with the dressing change if no visible droplets are on the supplies.
Explanation
A sterile field is considered contaminated whenever it is exposed to microorganisms, including those expelled during a cough — regardless of whether visible droplets are apparent. Microorganisms are not visible to the naked eye, so the absence of visible contamination does not guarantee sterility. The only safe course of action is to discard the compromised supplies and restart with a fresh sterile setup. Proceeding despite the cough (A) violates the fundamental principle that if sterility is in doubt, the field is considered contaminated. Covering with a sterile towel (B) does not retroactively sterilize already-contaminated items beneath it. Wiping with an alcohol swab and reusing supplies (D) confuses medical asepsis (cleaning) with surgical asepsis (sterility) — alcohol cleaning does not render items sterile.
How should the nurse proceed to maintain the highest level of asepsis?
Use the dominant hand to pick up the lubricant and continue the procedure.
Use the dominant hand to complete the procedure without using the lubricant.
Use the contaminated non-dominant hand to reach back into the sterile kit for the lubricant.
Ask a colleague to open a new lubricant packet and drop it onto the sterile field.
Explanation
During urinary catheterization, the non-dominant hand is used to separate and stabilize the labia, and once it contacts the client's perineal tissue it is considered contaminated for the remainder of the procedure. The dominant hand, however, remains sterile throughout and can safely retrieve items from the sterile field — including the lubricant packet. This hand-role division is a foundational principle of catheter insertion technique. Using the contaminated non-dominant hand to reach into the sterile kit (B) would contaminate the entire field and all remaining sterile equipment. Note that if a second nurse is present, Choice C (having a colleague drop a new lubricant packet onto the field) is also clinically acceptable; however, the standard answer assumes the nurse is working independently. Completing the procedure without lubricant (D) increases the risk of urethral trauma and is not appropriate.
Which action is the priority for the nurse?
Wash the contaminated glove with sterile saline and finish the procedure.
Remove the contaminated gloves and don a new pair of sterile gloves.
Apply an antibiotic ointment to the wound to prevent potential infection.
Continue the dressing change and document the contact with the bed rail.
Explanation
Contact between a sterile glove and any non-sterile surface — including the bed rail, which is a known reservoir of microorganisms — results in immediate, irreversible contamination of that glove. The nurse must remove the contaminated gloves and don a fresh sterile pair before continuing any contact with the wound. This is a non-negotiable principle of surgical asepsis: contamination is not a matter of degree. Continuing without replacing the gloves (A) introduces pathogens directly into a deep wound, significantly increasing infection risk. Rinsing with sterile saline (B) does not restore sterility; sterile saline cleans surfaces but cannot neutralize contamination on a glove. Applying antibiotic ointment (D) treats a potential consequence rather than correcting the immediate breach in technique and does not replace the need for sterile gloves.
After removing the old dressing with clean gloves, the nurse observes that the incision line is red, swollen, and has a small amount of purulent drainage. The nurse recognizes these findings as cues for:
Expected drainage for a client with diabetes.
Potential wound dehiscence or surgical site infection.
Normal inflammatory response during the healing process.
An allergic reaction to the previous adhesive tape.
Explanation
Purulent (pus-like) drainage combined with localized erythema and edema are cardinal signs of a surgical site infection (SSI). These findings are distinctly abnormal and must be reported and acted upon. Note that while the choice includes wound dehiscence — a separate complication referring to the mechanical separation of wound edges — the findings described here (redness, swelling, purulent drainage) are specifically consistent with SSI; dehiscence presents as visible wound edge separation, which may occur as a consequence of infection but is not itself evidenced by the current cues. Choice A is incorrect; normal wound inflammation (Days 1-4 post-op) produces mild redness and serous drainage — not purulent exudate. Purulence is never normal at any stage of healing. Choice C is not supported by the findings; contact dermatitis from tape typically causes rash at tape borders, not purulent drainage from the incision itself. Choice D is incorrect; purulent drainage is not an expected finding for any client regardless of diabetic status.
Based on the assessment of the wound, which nursing hypothesis should be the priority for the nurse's clinical judgment?
Impaired skin integrity related to surgical trauma.
Deficient knowledge related to post-operative care.
Risk for systemic infection related to wound contamination.
Acute pain related to the surgical incision.
Explanation
The presence of purulent wound drainage in an immunocompromised client — one with diabetes and obesity — signals a localized infection with the potential to spread systemically and progress to sepsis if not identified and contained. Risk for systemic infection is therefore the priority hypothesis because it carries the most serious and immediate threat to the client's life. Impaired skin integrity (A) is an accurate and relevant hypothesis but it describes an existing condition rather than the most dangerous potential consequence — it is subsumed within the broader concern about infection spread. Acute pain (C) warrants assessment and management but does not pose the same level of life-threatening risk. Deficient knowledge (D) is appropriate for discharge planning but is not a priority during an acute wound complication.
The nurse completes the sterile dressing change and documents the findings. Which outcome would indicate that the aseptic interventions were successful?
The wound shows no further increase in redness or purulent drainage over 24 hours.
The client reports that the pain has decreased from a 6 to a 2.
The client's blood glucose level remains within the target range.
The client can demonstrate how to remove the old dressing with clean gloves.
Explanation
The goal of strict sterile technique during a wound dressing change is to prevent the introduction of additional microorganisms and to support the conditions needed for wound healing. The most direct indicator of successful aseptic practice is stabilization of the wound — specifically, no worsening of redness, swelling, or purulent drainage over the subsequent 24 hours. This shows that the procedure did not introduce new pathogens and the existing infection is being contained. Pain reduction (A) is a valued clinical outcome but reflects analgesic effectiveness and overall comfort rather than aseptic success specifically. Blood glucose control (C) is critical for this diabetic client's healing trajectory but measures metabolic management, not the outcome of sterile technique. The client's ability to demonstrate dressing removal (D) is an educational outcome that supports future care but does not reflect the results of the sterile procedure performed.
Which instruction regarding asepsis should the nurse provide to the UAP?
You should wear a sterile gown when helping the client ambulate in the hall.
Always wash your hands with soap and water before and after touching the client.
You must use sterile gloves when assisting the client with a routine bed bath.
Make sure to keep all of the client's personal items on a sterile drape.
Explanation
Hand hygiene is the most fundamental and evidence-based principle of medical asepsis. It applies to every client interaction, regardless of the setting, procedure type, or perceived infection risk. Consistent hand hygiene before and after patient contact is the single most effective intervention to interrupt the chain of infection transmission. Sterile gloves (A) are required for sterile procedures — not for routine bed baths, which require clean gloves at most. Placing personal items on sterile drapes (C) applies sterile technique requirements to a non-sterile context where they are unnecessary and impractical. A sterile gown during ambulation (D) similarly misapplies surgical asepsis to a basic nursing activity.
How should the nurse interpret this occurrence?
Only the specific wet spot is contaminated; the rest of the field is safe.
The drape is still sterile because the saline used was sterile.
The field is safe to use once the saline has completely air-dried.
The entire sterile field is now contaminated by strike-through.
Explanation
Strike-through contamination occurs when moisture penetrates a sterile surface and creates a fluid bridge to a non-sterile surface beneath it. In this case, the sterile saline soaks through the drape and contacts the non-sterile table, allowing microorganisms from the table surface to migrate upward through the wet drape via capillary action — contaminating the entire sterile field above. The sterility of the saline itself is irrelevant once it has created this moisture pathway (A); it is the connection to the non-sterile surface that causes contamination. The contamination is not confined to the wet spot alone (C) because moisture and microbial migration are not limited to that exact location — the integrity of the entire field is considered compromised. Allowing the drape to air-dry (D) does not reverse contamination that has already occurred; once organisms have migrated through the moisture pathway, they remain on the field surface regardless of moisture level.
Which action should the nurse take first after opening the outer glove package?
Pick up the first glove by the cuff with the dominant hand.
Grasp the inside of the cuff of the first glove with the non-dominant hand.
Slide the dominant hand into the glove without touching the outer surface.
Use the gloved dominant hand to pick up the second glove by the cuff.
Explanation
The first step after opening the sterile glove package is to pick up the first glove (for the dominant hand) by grasping the inside of its folded cuff with the non-dominant bare hand. The key principle is that the inside of the glove cuff is the non-sterile portion — it is the surface that will contact the nurse's skin once the glove is on. Because it is non-sterile, a bare hand may safely touch it. The outer surface of the glove is the sterile surface that must not be touched by bare skin. Once the first glove is on the dominant hand, the sterile-gloved dominant hand picks up the second glove by sliding fingers under the outside of the cuff, touching only sterile surface. Choice A is incorrect; using the dominant hand to pick up the first glove would require it to touch the outer sterile surface before the glove is on. Choice C describes the second step, not the first. Choice B describes a later step (putting on the second glove) after the first glove is already donned.
Where should the nurse dispose of this specific item?
In the soiled linen hamper.
In the puncture-resistant sharps container.
In the regular trash can at the bedside.
In a red biohazard bag or container.
Explanation
Items saturated with blood or other potentially infectious body fluids are classified as regulated medical waste (biohazardous waste) and must be disposed of in a red biohazard bag or sealed biohazard container. This prevents exposure to bloodborne pathogens for housekeeping staff and others who handle waste, and ensures proper regulated disposal. Regular trash (A) is acceptable only for items that are not saturated — a small blood spot on gauze may qualify, but blood-soaked items do not, as they can drip or transfer infectious material. The sharps container (C) is designated for puncture-capable items such as needles, blades, and broken glass — not soft gauze. The linen hamper (D) is for contaminated textiles such as gowns and bed linens, not single-use disposable wound care items.