A nurse is preparing a client for a central line dressing change. Which of the following actions should the nurse take as part of the procedure?

Open the first flap of the sterile kit toward himself.

Ensure that the sterile field is located below waist level.

Place dry, sterile supplies 1/2 inch from the edge of the sterile field.

Apply sterile gloves after preparing the sterile field.

Answer and Explanation

The Correct Answer is C

A. Opening the first flap of the sterile kit away from the body helps maintain the sterility of the contents.
B. The sterile field should be above waist level to avoid contamination.

C. Placing dry, sterile supplies 1/2 inch from the edge of the sterile field helps prevent contamination of the items.
D. Sterile gloves should be donned before preparing the sterile field to avoid contamination.

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Correct Answer is D

Explanation

A. The two-point gait requires partial weight-bearing on both legs, making it unsuitable for a client who can only bear weight on one leg.
B. The four-point gait also requires weight-bearing on both legs and provides maximum stability, but it is not appropriate for a client who can bear weight on only one leg.
C. The swing-through gait is generally used by clients with paralysis of the legs or for those who need to use both legs minimally while moving with crutches. It is not the most suitable option for a client with weight-bearing restrictions on one leg.
D. The three-point gait is the correct technique for a client who can bear weight on only one leg. In this gait, both crutches and the affected leg are moved forward together, followed by the weight-bearing leg. This method allows the client to ambulate safely while maintaining the non-weight-bearing leg off the ground.

A. Decreased hematocrit B. Decreased specific gravity of urine C. Increased skin turgor D. Increased pulse rate

Correct Answer is D

Explanation

A. Decreased hematocrit may be seen in fluid volume excess, not deficit.

B. Decreased specific gravity of urine is more indicative of dilution rather than fluid volume deficit.
C. Increased skin turgor is a clinical manifestation of fluid volume deficit.

D. Increased pulse rate is a compensatory response to fluid volume deficit, reflecting the body's attempt to maintain perfusion in the setting of reduced blood volume.

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A nurse is preparing a client for a central line dressing change. Which of the following actions should the nurse take as part of the procedure?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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