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?

Drop the sterile gauze from 25.4 cm (10 in) above the sterile field.

Hold the sterile package in his dominant hand and open the top flap of the package toward his body.

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 A

Rationale:

A. Drop the sterile gauze from 25.4 cm (10 in) above the sterile field: Dropping sterile items from a height of about 6 to 12 inches prevents contamination by keeping hands outside the sterile field and ensuring the item lands safely without touching nonsterile surfaces.

B. 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 maintain sterility and prevent the arm from crossing over the sterile field, which would risk contamination.

C. Place objects 1.27 cm (0.5 in) inside the border of the sterile field: The outer 2.5 cm (1 inch) of the sterile field is considered contaminated. Placing items only 0.5 inches inside this border would place them within the contaminated zone, risking sterile field compromise.

D. Position the bottle outside the edge of the sterile field when pouring solution into a sterile container: While the bottle should not touch the sterile field, it must be close enough to pour without splashing, and the sterile container must be inside the sterile field.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:

A. Administer magnesium sulfate to the client: Magnesium sulfate is typically used for neuroprotection before 32 weeks or to manage preeclampsia; it is not indicated for rupture of membranes at 36 weeks unless there are other risk factors.

B. Administer betamethasone to the client: Betamethasone is used to enhance fetal lung maturity, most beneficial before 34 weeks. At 36 weeks, the lungs are usually mature enough that corticosteroids are not routinely indicated.

C. Monitor the client's temperature every 2 hr: This helps detect early signs of chorioamnionitis, a serious infection risk after membrane rupture, especially with prolonged rupture.

D. Monitor fetal heart rate every 4 hr: Fetal heart monitoring should be more frequent in the presence of membrane rupture to promptly identify signs of distress or infection, not every 4 hours.

A. "You are feeling anxious now; why don't you give it some time before making a final decision?" B. "You should talk with your family members before making this decision." C. "I will discuss this with your primary health care provider, and we can discuss this more tomorrow." D. "Let me refer you to talk to someone regarding your treatment options."

Correct Answer is D

Explanation

Rationale:

A. "You are feeling anxious now; why don't you give it some time before making a final decision?": This minimizes the client’s current emotional distress and does not address the seriousness of the statement. It may come across as dismissive rather than therapeutic.

B. "You should talk with your family members before making this decision.": Although involving family in major decisions can be helpful, the focus should be on the client's feelings and wishes first.

C. "I will discuss this with your primary health care provider, and we can discuss this more tomorrow.": Deferring the conversation may delay support for someone expressing emotional exhaustion and possible suicidal ideation. Prompt intervention is essential in these situations.

D. "Let me refer you to talk to someone regarding your treatment options.": This response acknowledges the client's emotional state while also offering a supportive and appropriate next step. It opens access to counseling or mental health services and helps the client explore options without judgment.

View Question and Answer

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

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 36 weeks of gestation and experiences a spontaneous rupture of membranes. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who has been on hemodialysis for the past 5 years. The client is refusing hemodialysis and says, "I'm tired of wasting my life; I would rather die." Which of the following statements should the nurse make?

Correct Answer is D

Explanation

A nurse is talking with the parents of a 2-month-old infant who have chosen to not immunize the infant. Which of the following responses should the nurse make?

A nurse is providing teaching to a client who has a depressive disorder and a new prescription for phenelzine. Which of the following foods should the nurse instruct the client to avoid?

A newly licensed nurse is caring for a client who requires tracheal suctioning, which is a procedure the nurse has not performed in practice. Which of the following actions should the nurse take?

A nurse is caring for a client. Exhibits Complete the following sentence by using the list of options. After notifying the provider, the nurse should first dropdown and then dropdown.

A nurse is caring for a client who has cancer and is being transferred to hospice care. The client's daughter tells the nurse, "I'm not sure what to say to my mom if she asks me about dying." Which of the following responses by the nurse is appropriate? (Select all that apply.)

A nurse on a postpartum unit is caring for a client. Exhibits Complete the following sentence by using the lists of options. The client is most likely experiencing dropdown as evidenced by the client's dropdown.

A nurse is preparing to assess a client for pulse deficit. Which of the following actions should the nurse plan to take?

A nurse preceptor is observing a newly licensed nurse caring for a client on a medical-surgical unit. Which of the following actions by the newly licensed nurse requires further instruction by the nurse preceptor?