A nurse is preparing a sterile field for the insertion of a urinary catheter. Identify the sequence of actions the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Perform hand hygiene.

Place the sterile package on the work surface.

Open the outermost flap of the package away from the body.

Open the side flaps of the package.

Open the innermost flap of the package toward the body.

Use the inner surface of the package as a sterile field.

Answer and Explanation

The Correct Answer is A,B,C,D,E,F

To prepare a sterile field for the insertion of a urinary catheter, the nurse should follow the sequence of actions in the following order:

1. Perform hand hygiene.

2. Place the sterile package on the work surface.

3. Open the outermost flap of the package away from the body.

4. Open the side flaps of the package.

5. Open the innermost flap of the package toward the body.

6. Use the inner surface of the package as a sterile field.

Following this sequence ensures that the nurse maintains proper hand hygiene, prepares the sterile package, and opens it in a way that maintains sterility. Opening the flaps in the correct order helps create a sterile field within the package, which can be used for the insertion of the urinary catheter.

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Correct Answer is A

Explanation

The purpose of the stool guaiac test, also known as the fecal occult blood test (FOBT), is to identify the presence of hidden or occult blood in the stool. This test is commonly performed to screen for gastrointestinal bleeding, which can indicate various conditions such as colorectal cancer, ulcers, polyps, or other sources of bleeding in the digestive tract.

The other options mentioned are not specifically detected by the stool guaiac test:

Parasites: The stool guaiac test does not directly detect parasites in the feces. Parasite testing requires a different type of analysis, such as microscopic examination or specialized laboratory tests.

Bacteria: The stool guaiac test does not specifically detect bacteria in the feces. If a bacterial infection is suspected, other diagnostic tests such as stool culture or polymerase chain reaction (PCR) may be ordered.

Fat: The stool guaiac test is not designed to detect fat in the feces. If there is a concern about fat malabsorption, other tests such as fecal fat analysis or Sudan stain may be used.

A. Peripheral edema B. Diarrhea C. Dry mouth D. Headache

Correct Answer is B

Explanation

After administering lactulose to a client with cirrhosis, the nurse should monitor for the adverse effects of diarrhea. Lactulose is a laxative commonly used in the treatment of hepatic encephalopathy, which can occur in individuals with cirrhosis. One of the intended effects of lactulose is to promote bowel movements and reduce the absorption of ammonia in the gut, thus helping to manage hepatic encephalopathy.

While lactulose can cause adverse effects such as diarrhea, it is not typically associated with peripheral edema. Peripheral edema is often seen in cirrhosis due to fluid retention caused by liver dysfunction.

Dry mouth and headache are less commonly associated with lactulose use and are not typically the primary adverse effects to monitor for in this scenario.

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A nurse is preparing a sterile field for the insertion of a urinary catheter. Identify the sequence of actions the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a prescription for a stool guaiac test. The client asks the nurse about the purpose of the test. The nurse should respond by stating that the stool guaiac is testing for which of the following findings in the client's feces?

Correct Answer is A

Explanation

A nurse is caring for a client who has cirrhosis and a prescription for lactulose. Following administration, the nurse should monitor the client for which of the following adverse effects?

Correct Answer is B

Explanation

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