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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Rationale:
A. Pain: Persistent or severe pain in a client at the end of life indicates the need for a palliative care consultation. Palliative care focuses on symptom relief, comfort, and quality of life through interdisciplinary management, particularly when standard treatments fail to control pain effectively.

B. Dysphagia: While it requires assessment and dietary modification, it does not independently warrant a palliative consultation unless associated with uncontrolled distress or nutritional compromise.

C. Fatigue: Fatigue is a frequent symptom at the end of life, typically managed through rest, activity pacing, and supportive care. Although it contributes to discomfort, it is not the primary trigger for initiating palliative care unless it severely affects the client’s comfort.

D. Mottling: Mottling is a physical sign of imminent death resulting from decreased circulation. At this stage, palliative or hospice care is often already in place, and new consultation would not alter the course of care.

A. Platelet count B. Alanine aminotransferase (ALT) C. Blood pressure D. Hemoglobin

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"B"}}

Explanation

Rationale:

• Platelet count: A drop in platelet count occurs in both preeclampsia and HELLP syndrome because of vascular endothelial damage leading to platelet aggregation and consumption. In HELLP, thrombocytopenia is often more severe, typically <100,000/mm³.

• Alanine aminotransferase (ALT): Elevated ALT reflects hepatocellular injury. It is a hallmark of HELLP syndrome (the “EL” = Elevated Liver enzymes) due to hepatic ischemia and microvascular damage, whereas in preeclampsia it may remain normal or only mildly elevated.

• Blood pressure: Hypertension (≥140/90 mm Hg) is the defining feature of preeclampsia and is also commonly seen in HELLP syndrome, which usually evolves from severe preeclampsia.

• Hemoglobin: Hemolysis (“H” in HELLP) results in decreased hemoglobin levels. In preeclampsia, hemoglobin levels are typically normal unless there is concurrent hemoconcentration or progression to HELLP syndrome.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at the end of life. Which of the following findings should indicate to the nurse a need for a palliative care consultation to be initiated?

Correct Answer is A

Explanation

The nurse is continuing to care for the client. Exhibits The nurse is reviewing the assessment findings. For each assessment finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process.

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"B"}}

Explanation

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