A nurse is preparing a sterile field for a client who requires a dressing change. Which of the following actions should the nurse plan to take?
Hold the sterile package in his dominant hand and open the top flap of the package toward his body.
Drop the sterile gauze from 25.4 cm (10 in) above the sterile field.
Place objects 1.27 cm (0.5 in) inside the border of the sterile field.
Position the bottle outside the edge of the sterile field when pouring solution into a sterile container.
The Correct Answer is D
Rationale:
A. Hold the sterile package in his dominant hand and open the top flap of the package toward his body: The top flap should be opened away from the nurse’s body to avoid reaching over and contaminating the sterile field. Opening toward the body risks touching or dropping contaminants onto the field.
B. Drop the sterile gauze from 25.4 cm (10 in) above the sterile field: Sterile items should be dropped from a minimal height, close to the field, to prevent them from bouncing, falling off, or becoming contaminated. A 10-inch drop increases the risk of contamination.
C. Place objects 1.27 cm (0.5 in) inside the border of the sterile field: The outer 1 inch (2.5 cm) of a sterile field is considered contaminated, not just 0.5 inches. Placing objects inside only 0.5 in does not guarantee sterility and may result in contamination.
D. Position the bottle outside the edge of the sterile field when pouring solution into a sterile container: Keeping the bottle outside the sterile field prevents contamination from the outside of the bottle. Only the sterile contents should enter the sterile container, maintaining the integrity of the sterile field during the dressing change.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Rationale for Correct Choices
• Evaluating the fetal heart rate tracing: The client presents with severe preeclampsia, as indicated by hypertension (166/110 mm Hg), 3+ proteinuria, and hyperreflexia. The priority is to assess fetal well-being since decreased fetal movement and maternal hypertension can compromise placental perfusion, placing the fetus at risk for hypoxia or distress.
• Administering magnesium sulfate IV: Once fetal assessment confirms stability, magnesium sulfate should be initiated to prevent eclamptic seizures. This medication stabilizes the central nervous system by reducing neuromuscular excitability and cerebral irritation associated with severe preeclampsia.
Rationale for Incorrect Choices
• Administering acetaminophen PO: The client already reported that acetaminophen was ineffective for headache relief. The headache is a sign of severe preeclampsia, not a benign pain complaint, so administering more acetaminophen does not address the underlying pathology.
• Obtaining 24-hour urine collection: While important for confirming the degree of proteinuria, this action is not an immediate priority. Stabilizing maternal and fetal conditions takes precedence over diagnostic collection.
• Inserting an indwelling urinary catheter: The catheter is required for strict intake and output monitoring during magnesium therapy, but it is not performed before ensuring fetal stability and initiating seizure prophylaxis.
• Administering betamethasone IM: Betamethasone promotes fetal lung maturity, which is appropriate in preterm conditions; however, it is not the immediate priority. Seizure prevention and fetal assessment are more urgent interventions at this stage.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"A"}}
Explanation
Rationale:
• Encourage naps during the day when client is tired: Daytime napping can interfere with nighttime sleep quality and reduce trazodone’s effectiveness in reestablishing a normal sleep pattern.
• Advise client to rise slowly from sitting position: Trazodone can cause orthostatic hypotension, particularly when therapy is initiated. Educating the client to change positions slowly helps prevent dizziness and potential falls caused by sudden drops in blood pressure.
• Instruct client to avoid foods that have been fermented or aged: This instruction applies to MAOIs due to the risk of hypertensive crisis from tyramine, but trazodone is a serotonin antagonist and reuptake inhibitor, not an MAOI.
• Encourage client to sleep until later in the morning: Oversleeping disrupts the circadian rhythm and may worsen fatigue. The goal is to maintain a stable sleep-wake cycle to enhance mood and energy regulation.
• Encourage a regular sleep-wake schedule: Establishing consistent sleep routines supports trazodone’s sedative effects and helps regulate the client’s circadian rhythm, improving overall sleep quality without disrupting normal activity patterns.
• Advise client to notify provider if pregnant: Trazodone is classified as pregnancy category C, meaning potential fetal risks exist. The client should notify the provider to evaluate the safety of continuing or adjusting medication during pregnancy.
• Encourage high-calorie finger foods: The client’s BMI has decreased, and trazodone may cause appetite suppression. Offering convenient, calorie-dense snacks helps maintain adequate nutrition and prevents further weight loss.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.