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 B

Explanation

Peptic ulcer disease is characterized by open sores that develop on the lining of the stomach, small intestine, or esophagus. The symptoms and pain associated with peptic ulcer disease can

vary, but certain patterns are commonly observed: "The pain is worse after I eat a meal high in fat": This statement aligns with the typical symptom of peptic ulcer disease. The presence of fat in the stomach triggers the release of certain hormones and substances that stimulate gastric acid secretion. This increased acid production can exacerbate the pain experienced by individuals with peptic ulcers.

"I feel so much better after eating": Feeling relief after eating is not characteristic of peptic ulcer disease. In fact, individuals with peptic ulcers may experience pain or discomfort after eating especially those with gastric ulcers.

"The pain radiates down to my lower back": Lower back pain is not a common symptom associated specifically with peptic ulcer disease. Radiating pain to the back is more commonly associated with conditions like pancreatitis or kidney issues.

"My pain is relieved by having a bowel movement": Pain relief with bowel movements is not a typical symptom of peptic ulcer disease. It may be more indicative of conditions like irritable bowel syndrome or inflammatory bowel disease.

A. "Daily bowel movements are necessary for good intestinal health.” B. "Chronic use of laxatives can lead to a tear in the rectal mucosa" C. "Decrease your intake of high-fiber foods." D. "Excessive laxative use can cause an electrolyte imbalance.”

Correct Answer is D

Explanation

Bisacodyl is a stimulant laxative commonly used to treat constipation. However, it is important to educate the client about the potential risks associated with chronic laxative use. The statement regarding electrolyte imbalance is important because excessive or prolonged use of laxatives can lead to electrolyte disturbances, such as low potassium levels (hypokalemia), which can have adverse effects on various body functions.

"Daily bowel movements are necessary for good intestinal health": While regular bowel movements are generally desirable, stating that daily bowel movements are necessary for good intestinal health is an overgeneralization. Bowel movement frequency can vary among individuals, and it is important to consider other factors such as diet, hydration, and overall health.

"Chronic use of laxatives can lead to a tear in the rectal mucosa": While chronic use of laxatives can lead to complications such as dependence and potential damage to the digestive system, specifically mentioning a tear in the rectal mucosa (rectal mucosal injury) is not the most commonly associated concern.

"Decrease your intake of high-fiber foods": It is generally recommended to increase fiber intake for individuals with constipation. Decreasing high-fiber foods would counteract the benefits of dietary fiber in promoting regular bowel movements and alleviating constipation.

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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 collecting data from a client in the health clinic who is reporting epigastric pain. Which of the following statements made by the client should the nurse identify as being consistent with peptic ulcer disease?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a client who reports taking bisacodyl daily. Which of the following information should the nurse include?

Correct Answer is D

Explanation

A nurse is preparing to administer dextrose 5% in 0.45% sodium chloride 1000 mL to infuse at 100 mL/60 min. The drop factor on the manual IV tubing is 60 gtt/mL. The nurse should set the IV flow rate to deliver how many gtt/min? (Round to the nearest whole number.)

A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the following findings should the nurse identify as a risk factor for this condition?

A nurse is reinforcing teaching for a client who has a duodenal ulcer and a new prescription for sucralfate. The client asks the nurse how sucralfate works. Which of the following statements should the nurse make?

A nurse is preparing to administer 0.9% sodium chloride (NS) 100 mL IV to infuse over 4 hr. The drip factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number.)

A nurse is reinforcing teaching a client who has peptic ulcer disease and is starting therapy with sucralfate. Which of the following instructions should the nurse include in the teaching?

A nurse is reinforcing teaching with a client who has a new prescription for aluminum hydroxide to treat heartburn. Which of the following adverse effects of the medication should the nurse include in the teaching?

A nurse is planning care for a client who has a peptic ulcer and a new prescription for sucralfate 2 gm administered twice daily. Which of the following times should the nurse plan to administer the medication?

A nurse is collecting data from a client who has peptic ulcer disease. Which of the following findings is a manifestation of gastrointestinal perforation?