A charge nurse is observing a nurse perform a sterile dressing change for a client. Which of the following actions should the charge nurse identify as demonstrating sterile technique?

The nurse places the sterile package with the top flap opening away from the body.

The nurse pinches the flap on the inside of the package first to open it.

The nurse reaches over the package to open the left flap.

The nurse pulls the last flap of the package away from the body.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Placing the sterile package with the top flap opening away from the body is the correct choice. This technique helps maintain the sterility of the contents by preventing potential contamination from the nurse's body and clothing.

Choice B rationale:

Pinching the flap on the inside of the package first to open it is not a recommended sterile technique. It could potentially introduce contamination from the nurse's hand into the sterile field when pinching the inner flap.

Choice C rationale:

Reaching over the package to open the left flap is not the ideal technique. Reaching over the sterile field can introduce the risk of contamination, as the nurse's arm and body might come into contact with the sterile supplies.

Choice D rationale:

Pulling the last flap of the package away from the body is not the most effective technique. This action could potentially lead to the nurse's hand coming close to or over the sterile field, increasing the risk of contamination.

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Correct Answer is C

Explanation

Choice A rationale:

Digoxin is a medication used to treat heart conditions like heart failure and atrial fibrillation. A digoxin level of 1.0 ng/mL is within the therapeutic range (usually 0.5-2.0 ng/mL), indicating that the client's digoxin dosage is appropriate. However, this value doesn't indicate an urgent need for a home visit.

Choice B rationale:

A white blood cell count (WBC) of 6,000/mm³ falls within the normal range (typically 4,500-11,000/mm³). While this value could suggest a stable immune system, it doesn't provide information requiring immediate attention or a home visit.

Choice C rationale:

Platelets are essential for blood clotting. A platelet count of 100,000/mm³ is significantly below the normal range (usually 150,000-450,000/mm³), indicating a risk of bleeding and potentially a serious medical condition. This client is at risk for spontaneous bleeding and requires prompt assessment and intervention, making this choice the correct answer.

Choice D rationale:

A serum potassium level of 4.0 mEq/L falls within the normal range (typically 3.5-5.0 mEq/L). While maintaining electrolyte balance is important, this potassium level doesn't indicate an immediate need for a home visit.

A. Assist clients who are in immediate danger to a safe location. B. Close doors and windows on the unit. C. Attempt to extinguish the fire using an ABC fire extinguisher. D. Discontinue oxygen use for clients who can breathe without it.

Correct Answer is A

Explanation

Choice A rationale:

The nurse's first priority in the event of a fire is the safety and well-being of the clients. Clients who are in immediate danger due to the fire should be assisted to a safe location as quickly as possible. This choice is supported by the principles of prioritizing client safety during emergencies.

Choice B rationale:

Closing doors and windows on the unit is a secondary action and comes after ensuring the safety of clients in immediate danger. While it can help contain the fire's spread, it should not be the nurse's first action, as it does not address the immediate risk to clients' lives.

Choice C rationale:

Attempting to extinguish the fire using an ABC fire extinguisher might be a consideration in emergency situations; however, the nurse's first responsibility is to ensure the safety of clients. The nurse should not put themselves or clients at risk by attempting to extinguish the fire before moving clients to safety.

Choice D rationale:

Discontinuing oxygen use for clients who can breathe without it is not the nurse's primary action during a fire emergency. While it's important to manage resources, such as oxygen, the immediate focus should be on evacuating clients from the danger zone.

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A charge nurse is observing a nurse perform a sterile dressing change for a client. Which of the following actions should the charge nurse identify as demonstrating sterile technique?

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