A nurse is preparing a sterile field to perform a dressing change of a client's leg wound. Which of the following actions should the nurse take?
Hold the irrigation solution bottle 5 cm (2 in) above the sterile container.
Open the outer wrapper of the sterile package toward her body.
Place the irrigation solution bottle cap on the sterile field.
Place sterile objects at least 2.5 cm (1 in) from the edge of the sterile field.
The Correct Answer is D
A. Holding the irrigation solution bottle 5 cm (2 in) above the sterile container is incorrect because the solution should be poured into a sterile container without contaminating the sterile field. The nurse should pour the solution from a height that avoids splashing and contamination.
B. Opening the outer wrapper of the sterile package toward her body is incorrect. The outer wrapper of a sterile package should be opened away from the body to avoid contamination of the sterile field.
C. Placing the irrigation solution bottle cap on the sterile field is incorrect. The cap should not be placed on the sterile field, as it may introduce contaminants.
D. Placing sterile objects at least 2.5 cm (1 in) from the edge of the sterile field is correct. This practice maintains the sterility of the field by preventing contamination from external sources.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Anorexia: This is not a common or serious adverse effect of heparin. It is not usually a priority for reporting to the provider.
B. Epistaxis: This is correct. Heparin is an anticoagulant, and one of the major risks associated with its use is bleeding. Epistaxis (nosebleeds) is a common sign of bleeding that could be a result of heparin therapy, and it should be reported to the provider promptly.
C. Bradycardia: Bradycardia is not a common adverse effect of heparin. Heparin primarily affects clotting mechanisms, not heart rate.
D. Weight gain: Weight gain is not a typical adverse effect of heparin. If the weight gain is significant or linked to fluid retention, it may need to be assessed, but it is not a typical reaction to heparin.
Correct Answer is D
Explanation
A. Stating that palliative care is only for clients with a terminal illness is incorrect. Palliative care is designed for clients with serious, chronic, or life-threatening illnesses and focuses on symptom management and quality of life, regardless of prognosis.
B. Limiting palliative care to those with 6 months or less to live is incorrect. This definition applies to hospice care, not palliative care. Palliative care can be provided alongside curative treatments at any stage of illness.
C. Including restriction of nutritional support is incorrect. Palliative care emphasizes comfort and symptom relief, including providing adequate nutrition and hydration as appropriate for the client’s needs and wishes.
D. Enhancing quality of life by promoting comfort is correct. Palliative care aims to relieve symptoms such as pain, nausea, and fatigue while supporting the client’s emotional, psychological, and spiritual well-being.
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