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 C
Explanation
A. Urinary catheter: A urinary catheter is not routinely required for infants with a spica cast. Unless there are specific urinary retention issues or surgical complications, normal voiding is expected, and a catheter would introduce unnecessary risk for infection.
B. Wound vac: A wound vac is used for complex wound management involving significant drainage or delayed healing. Infants with a spica cast typically do not have open wounds that necessitate negative pressure wound therapy, making this equipment unnecessary for discharge.
C. Car seat: A special car seat or car bed is necessary for safe transportation of an infant in a spica cast, as standard car seats cannot accommodate the wide leg positioning. Proper fitting ensures both safety and compliance with transportation regulations during discharge.
D. Feeding pump: A feeding pump is typically used for clients requiring continuous enteral feeding. Unless the infant has a separate feeding disorder or gastrointestinal complication, feeding by mouth is expected, and a feeding pump would not be standard discharge equipment.
Correct Answer is D
Explanation
A. Cantaloupe: Cantaloupe is considered high in potassium, with about 430 mg of potassium per cup. This makes it unsuitable for a client needing a low-potassium diet, as it can significantly contribute to elevated potassium levels.
B. Sweet potato: Sweet potatoes are very high in potassium, containing around 540 mg of potassium per half-cup serving. They are not recommended for individuals trying to manage or lower their potassium intake.
C. Orange juice: Orange juice provides approximately 500 mg of potassium per 1-cup serving. It is commonly avoided or limited in potassium-restricted diets due to its significant contribution to total potassium intake.
D. Wheat bread: Wheat bread contains a relatively low amount of potassium, about 60 to 70 mg per slice. Compared to the other options listed, wheat bread is much lower in potassium and is a better choice for clients who need to restrict potassium in their diet.
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