A charge nurse is educating a newly licensed nurse on how to perform a sterile dressing change on a client. Which of the following action indicates an understanding of the teaching?
The nurse handled the sterile gauze with clean gloves on.
The nurse opened the package of gauze toward their body.
The nurse placed a bottle of saline on the sterile field.
The nurse kept their hands above the waist during the dressing change.
The Correct Answer is D
A. The nurse handled the sterile gauze with clean gloves on: Handling sterile gauze with clean, non-sterile gloves contaminates the gauze and compromises the sterile field. Sterile gloves or sterile instruments must be used to maintain sterility.
B. The nurse opened the package of gauze toward their body: Opening a sterile package toward the body increases the risk of contaminating the sterile field. The first flap should always be opened away from the body to maintain proper sterile technique.
C. The nurse placed a bottle of saline on the sterile field: Placing a non-sterile item, such as an unsterilized saline bottle, onto a sterile field contaminates the entire field. Only sterile items should touch the sterile field.
D. The nurse kept their hands above the waist during the dressing change: Maintaining hands above the waist is crucial in sterile technique. Anything held below waist level is considered contaminated, so this action shows proper understanding of maintaining sterility.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Hypertension: Hyponatremia typically leads to hypotension due to fluid shifts out of the vascular space rather than hypertension, especially if it is associated with hypovolemia. Low sodium levels can reduce blood volume and pressure, making hypertension an unlikely finding in this condition.
B. Muscle cramps: Muscle cramps are a common symptom of hyponatremia due to disrupted electrolyte balance affecting neuromuscular function. Low sodium levels impair muscle contraction and nerve signal transmission, leading to cramps, weakness, and fatigue.
C. Blurred vision: Blurred vision is not a typical manifestation of hyponatremia. While severe hyponatremia can cause neurological symptoms like confusion or seizures, visual disturbances like blurred vision are not primary signs linked to sodium imbalance.
D. Constipation: Constipation is more often associated with dehydration, immobility, or other electrolyte imbalances such as hypercalcemia. Hyponatremia primarily affects neuromuscular and central nervous system function rather than gastrointestinal motility.
Correct Answer is C
Explanation
A. "Your baby needs to suck on a pacifier.": While non-nutritive sucking on a pacifier can sometimes soothe a fussy baby, it is not the first recommendation, especially for a newborn who is establishing breastfeeding. Early introduction of pacifiers can interfere with successful breastfeeding due to nipple confusion.
B. "Breastfed babies are usually fussy from swallowing too much air during feedings.": Although some air swallowing can occur, especially if the latch is poor, this is not typically the primary reason for persistent crying. Addressing crying with soothing techniques like swaddling is a more immediate and supportive intervention for the parent.
C. "Swaddling your baby snugly in a blanket might help soothe her.": Swaddling provides warmth, security, and a sense of being back in the womb, which can calm a newborn effectively. It reduces the startle reflex and helps regulate the baby's nervous system, often resulting in decreased crying and improved comfort.
D. "Breastfed babies often need to be supplemented with formula.": Routine supplementation with formula is not recommended for healthy breastfed newborns unless there are clear medical indications. Promoting exclusive breastfeeding supports optimal nutrition, bonding, and gut health in the early postpartum period.
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