The nurse is providing care for patients on the medical-surgical unit. Which of the following situations requires the nurse to implement medical asepsis?

Applying sterile gloves to assist with a procedure.

Inserting an indwelling urinary catheter.

Preparing injectable medications.

Picking up soiled tissues off of the bedside table.

Answer and Explanation

The Correct Answer is D

A. Applying sterile gloves to assist with a procedure: This is part of surgical asepsis (sterile technique) rather than medical asepsis.
B. Inserting an indwelling urinary catheter: This requires sterile technique, not just medical asepsis.
C. Preparing injectable medications: Medication preparation requires aseptic (sterile) technique to prevent contamination.
D. Picking up soiled tissues off of the bedside table: Medical asepsis includes hand hygiene and proper handling of contaminated items to prevent the spread of infection.

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Correct Answer is D

Explanation

A. 89-year-old with dementia and NG tube with continuous tube feeding: While this patient requires monitoring, continuous tube feeding is routine, and there is no indication of immediate distress.

B. 73-year-old with hypoactive bowel sounds one day post-cholecystectomy: Hypoactive bowel sounds are expected after surgery, particularly after abdominal procedures. This does not indicate an emergency.

C. 43-year-old with anorexia and nausea for two days who is tolerating a clear liquid diet: This patient’s condition is stable, and nausea is resolving, making them a lower priority.

D. 65-year-old who has dysphagia after suffering from a stroke who is NPO: Dysphagia (difficulty swallowing) increases the risk of aspiration pneumonia, which can be life-threatening. This patient should be assessed first to ensure their airway is protected.

A. Check the patient's urinalysis. B. Notify the provider of the patient's pain 7/10 C. Perform a bladder scan D. Assess the daily weight.

Correct Answer is C

Explanation

A. Check the patient's urinalysis. While a urinalysis may provide useful information (e.g., infection, kidney function), it does not address the immediate concern—significantly decreased urine output despite adequate intake. The priority is to determine urinary retention first.

B. Notify the provider of the patient's pain 7/10. While pain management is important, the more critical issue is the drastically low urine output (150mL in 12 hours), which could indicate acute urinary retention or renal dysfunction. Addressing the urinary issue should come first.

C. Perform a bladder scan. The low urine output (150mL in 12 hours) despite sufficient intake (2150mL) suggests potential urinary retention. A bladder scan is the quickest and least invasive way to determine if the patient has a full bladder that needs intervention (e.g., catheterization). This is the priority before further testing or notifying the provider.

D. Assess the daily weight. Daily weight monitoring is helpful for fluid status assessment, especially in cases of heart failure or kidney disease, but it is not the most immediate priority. The primary concern is whether the patient has urinary retention, which requires urgent evaluation.

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The nurse is providing care for patients on the medical-surgical unit. Which of the following situations requires the nurse to implement medical asepsis?

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