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 C
Explanation
A. Tachypnea: Tachypnea (rapid breathing) is not a typical effect of magnesium sulfate. Magnesium sulfate is more likely to cause respiratory depression, especially at higher doses, rather than increasing the rate of breathing.
B. Tachycardia: Tachycardia (rapid heart rate). is not a common finding with magnesium sulfate administration. Magnesium sulfate typically causes a decrease in heart rate (bradycardia. and may also contribute to hypotension.
C. Hypotension: Hypotension is the correct finding. Magnesium sulfate has a vasodilatory effect, which can lead to a drop in blood pressure. This is a well-known side effect of magnesium sulfate, particularly when administered intravenously.
D. Hyperthermia: Hyperthermia (elevated body temperature). is not a typical finding associated with magnesium sulfate. Instead, magnesium sulfate can sometimes cause mild flushing, but it does not generally lead to an increase in body temperature.
Correct Answer is D
Explanation
A. "My partner and I will use petroleum jelly with latex condoms.": Petroleum jelly should not be used with latex condoms as it can weaken the latex material, increasing the risk of condom breakage. Water-based lubricants are recommended with latex condoms.
B. "My partner and I will both use a condom during intercourse.": This is not necessary or recommended. Only one condom is needed, and using two (male and female condom) may cause friction and increase the likelihood of breakage.
C. "I will be able to remove my contraceptive sponge immediately after intercourse.": The sponge should be left in place for at least 6 hours after intercourse to allow its spermicide to be effective. Removing it immediately could reduce the effectiveness of the contraceptive.
D. "My partner will use condoms with spermicides, which works better.": This statement demonstrates understanding. Using condoms with spermicides can be an effective form of contraception, as the spermicide helps to kill or immobilize sperm, providing an additional layer of protection.
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