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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The nurse should measure the gastric residual before administering a feeding to identify delayed gastric emptying. Gastric residual refers to the volume of formula or contents remaining in the stomach from the previous feeding. Measuring gastric residual helps assess how well the client's stomach is emptying and can indicate if there is delayed gastric emptying.
By measuring gastric residual, the nurse can:
● Determine if the stomach has adequately emptied from the previous feeding. ● Assess the client's tolerance to enteral feedings.
● Detect signs of delayed gastric emptying, which can be indicative of gastrointestinal motility issues or other complications.
● Adjust the feeding rate or make other modifications to the enteral feeding plan based on the amount of residual volume.
Confirming the placement of the NG tube is typically done using other methods, such as an X-ray, pH testing, or auscultation of air insufflation. Gastric residual measurement primarily serves the purpose of assessing gastric emptying, rather than confirming tube placement.
While electrolyte imbalances can be monitored in the overall care of a client receiving enteral feedings, measuring gastric residual specifically focuses on assessing gastric emptying and feeding tolerance, rather than determining the client's electrolyte balance.
Removing gastric acid that might cause dyspepsia is not the primary purpose of measuring gastric residual. Gastric residual measurement aims to evaluate the volume of the previous feeding and assess gastric emptying, rather than focusing on dyspepsia specifically.
Correct Answer is ["1"]
Explanation
The nurse typically auscultates the abdomen for bowel sounds before meals or at least 1-2 hours after meals. This timing allows for the assessment of both the presence and character of bowel sounds. It is important to note that bowel sounds can vary depending on factors such as the client's activity level, diet, and any underlying gastrointestinal conditions. Therefore, a comprehensive assessment of bowel sounds should be conducted at different times to obtain an accurate representation of the client's bowel function.
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