A nurse is performing a head to toe assessment on a client. Which of the following assessment findings would the nurse recognize as requiring an immediate action and would be the first priority when addressing a patient health problem?

Pallor.

Jaundice.

C. Cyanosis.

Erythema.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. Cyanosis. Cyanosis is a medical emergency and requires immediate action by the nurse. It indicates that the client is not receiving adequate oxygenation and can lead to respiratory failure if not addressed promptly. Pallor (Option A) and erythema (Option D) are concerning but are not immediate priorities compared to cyanosis. Jaundice (Option B) may indicate liver dysfunction but is not an immediate priority unless it is associated with other symptoms such as severe abdominal pain or altered mental status.

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Correct Answer is C

Explanation

Correct answer: C

C. The nurse turns and their back is facing the sterile field.Turning one’s back to the sterile field is a breach of sterile technique because it increases the risk of contamination. The sterile field must always be in the nurse’s line of sight to ensure it remains uncontaminated.

Incorrect Options:

A. The nurse applies sterile gloves and touches a sterile object in the sterile field.This is correct practice. Sterile gloves are used to handle sterile objects within the sterile field to maintain sterility.

B. The nurse disposes of an opened container of sterile saline after 24 hours.This is correct practice. Sterile saline should be discarded after 24 hours to prevent contamination.

D. The nurse keeps hands above waist level while donning sterile gloves.This is correct practice. Keeping hands above waist level helps maintain sterility by preventing contact with non-sterile surfaces.

Correct Answer is ["725"]

Explanation

IV Fluid Intake:
- From 0700 to 0900: 2 hours × 100 mL/hr = 200 mL
- From 1030 to 1530: 5 hours × 100 mL/hr = 500 mL
- Total IV Fluid Intake: 200 mL + 500 mL = 700 mL
Antibiotic Infusion Intake:
- Antibiotic Solution: 25 mL
Total Intake Calculation:
- IV Fluid Intake: 700 mL
- Antibiotic Infusion: 25 mL
- Total Intake: 700 mL + 25 mL = 725 mL

Answer: The total intake for the patient from 0700 to 1530 is 725 mL.

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A nurse is performing a head to toe assessment on a client. Which of the following assessment findings would the nurse recognize as requiring an immediate action and would be the first priority when addressing a patient health problem?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A new perioperative nurse is being educated regarding surgical asepsis. What observations by the preceptor would indicate that there is a need for further education and reinforcement of the principles of asepsis?

Correct Answer is C

Explanation

Correct Answer is ["725"]

Explanation

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