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 D
Explanation
A. Copy of the client's advance directives: While advance directives are important documents, they are typically filed with the medical record, not specifically included in postmortem documentation. The focus for postmortem documentation is on the body and relevant events surrounding the death.
B. Cause of the client's death.: The cause of death is typically recorded in the official death certificate, which is not part of postmortem nursing documentation. The nurse should not make a diagnosis about the cause of death but may note any relevant findings.
C. Last set of the client's vital signs: Vital signs taken at the time of death may be noted as part of the clinical documentation, but they are not specifically part of postmortem documentation. The postmortem documentation should focus on observations regarding the body and its condition.
D. Location of the identification tag on the client’s body: The nurse should document the location of identification tags on the body to ensure proper identification and to prevent confusion or errors in postmortem care. This is an important detail in postmortem documentation.
Correct Answer is A
Explanation
A. Chadwick's sign is correct. Chadwick's sign refers to a purplish or bluish discoloration of the vagina and vulva that occurs early in pregnancy due to increased blood flow to the pelvic area. This is typically seen around the 8th week of gestation.
B. Hegar's sign is incorrect. Hegar's sign refers to the softening of the lower uterine segment, which is a physical change that can be felt during a pelvic examination. It is a sign of pregnancy but does not involve discoloration of the vaginal area.
C. Chloasma is incorrect. Chloasma, also called the "mask of pregnancy," refers to hyperpigmentation on the face, typically over the cheeks and forehead, not the vagina or vulva.
D. Ballottement is incorrect. Ballottement refers to a physical finding during a pelvic exam in which the examiner can feel the fetus floating in the amniotic fluid, typically observed after 16 weeks of pregnancy. It is unrelated to changes in vaginal or vulvar color.
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