The nurse is preparing to insert a urinary catheter. The nurse is using open gloving to apply the sterile gloves. Which steps will the nurse take? (Select all that apply.)
While putting on the first glove, touch only the outside surface of the glove.
Remove outer glove package by tearing the package open.
After the second glove is on, interlock hands.
With gloved dominant hand, slip fingers underneath the second glove cuff.
Lay glove package on clean flat surface above waistline.
Glove the dominant hand of the nurse first.
Correct Answer : B,C,D,E,F
A. This statement is incorrect; the nurse should touch only the inside of the first glove while putting it on to maintain sterility.
B. The outer glove package should be removed by tearing it open to access the gloves inside.
C. After putting on the second glove, interlocking hands helps to ensure that the gloves remain sterile.
D. Slipping fingers underneath the second glove cuff with the gloved dominant hand helps to keep the gloves sterile while donning them.
E. Laying the glove package on a clean flat surface above the waistline prevents contamination.
F. The dominant hand should be gloved first to maintain a sterile technique, as the dominant hand is used for the procedure.
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Correct Answer is A
Explanation
A. "Readiness for enhanced urinary elimination" is classified as a health promotion diagnosis, indicating the patient’s desire to improve their health condition and adopt new health behaviors.
B. A risk diagnosis is used when there is a potential for problems to occur, not applicable in this scenario as the patient is actively seeking improvement.
C. A problem-focused diagnosis describes an existing problem that requires intervention; this situation reflects readiness for improvement, not an existing issue.
D. A collaborative problem involves potential complications that require both nursing and medical management; this case focuses on the patient's willingness to learn a self-management skill rather than managing a specific medical problem.
Correct Answer is D
Explanation
A. The superior vena cava is responsible for returning deoxygenated blood from the upper body to the heart and is not directly involved in myocardial ischemia.
B. The carotid artery supplies blood to the brain and is not the primary focus in the context of myocardial infarction.
C. The pulmonary artery carries deoxygenated blood from the heart to the lungs and is not involved in coronary circulation.
D. The coronary arteries supply blood to the heart muscle itself. Ischemia during a myocardial infarction occurs when these arteries are blocked or narrowed, leading to a lack of blood flow and oxygen to the heart tissue.