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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. "I can prevent nausea if I take the medication on an empty stomach." This is incorrect. Taking ferrous sulfate on an empty stomach may increase the risk of gastrointestinal upset, including nausea. It is typically recommended to take it with food to reduce these side effects, although it may be less effective if taken with certain foods or beverages.

B. "I can prevent constipation if I drink more milk while taking this medication." This is incorrect. Milk can actually worsen constipation, and clients taking ferrous sulfate should focus on increasing fiber intake and drinking plenty of fluids to prevent constipation.

C. "I will report black stools to my doctor." This is correct. Black stools are a common side effect of iron supplementation, but it is essential for the client to report it to the doctor if they are concerned, as it could also indicate gastrointestinal bleeding in some cases.

D. "I will mix the medication with a full glass of water." While taking the medication with a full glass of water is appropriate, it is not the most significant instruction regarding the use of the medication. Therefore, while the answer isn't wrong, it doesn't indicate the client's understanding of the most important aspects, such as monitoring for side effects like black stools.

A. "I should keep my baby rear-facing in the car seat until she is 2 years old." B. "I should position the car seat's retainer clip at the level of my baby's belly button." C. "I should enable the airbag when my baby is in the front seat of the car." D. "I should place my baby in the car seat at a 90-degree angle."

Correct Answer is A

Explanation

A. "I should keep my baby rear-facing in the car seat until she is 2 years old.": This is correct. The American Academy of Pediatrics recommends that infants and toddlers remain in a rear-facing car seat until they are at least 2 years old or until they reach the height and weight limits specified by the car seat manufacturer. Rear-facing provides the best protection for the baby's head, neck, and spine in the event of an accident.

B. "I should position the car seat's retainer clip at the level of my baby's belly button.": This is incorrect. The retainer clip should be positioned at armpit level, not at the belly button. This ensures the harness fits snugly and securely around the baby.

C. "I should enable the airbag when my baby is in the front seat of the car.": This is incorrect. Airbags should never be enabled when a baby is sitting in the front seat, as they can cause injury in the event of a collision. The baby should always be seated in the back seat of the car, as it is the safest location.

D. "I should place my baby in the car seat at a 90-degree angle.": This is incorrect. The car seat should be reclined at an angle of approximately 45 degrees to ensure the baby’s head does not fall forward, which could compromise breathing. A 90-degree angle is too upright and may be unsafe for a newborn.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has a prescription for ferrous sulfate elixir. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is reinforcing teaching about car seat safety with a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching?

Correct Answer is A

Explanation

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