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 A

Explanation

A. Reduced fat in the stools is correct. Pancrelipase is an enzyme replacement therapy that helps improve digestion and absorption of fats and proteins in individuals with cystic fibrosis. This treatment is especially important for those with pancreatic insufficiency, as it helps prevent the steatorrhea (fatty stools) commonly seen in these patients.

B. Decreased sodium excretion is incorrect. Pancrelipase does not directly affect sodium balance in the body. Cystic fibrosis patients may experience increased sodium excretion, which requires special management of fluid and electrolytes.

C. Improved respiratory function is incorrect. While pancrelipase improves digestion, it does not directly affect respiratory function, which is primarily impacted by the progressive lung disease in cystic fibrosis.

D. Improved absorption of vitamins B and C is incorrect. While pancrelipase helps with fat absorption, it primarily improves the absorption of fat-soluble vitamins (A, D, E, K) rather than water-soluble vitamins like B and C.

A. Encourage the toddler to flush the toilet while still seated. B. Have the toddler remain on the toilet for a minimum of 20 min. C. Wake the toddler every 2 hr. in the night to prevent bed-wetting. D. Give the toddler a sticker after each successful toileting attempt.

Correct Answer is D

Explanation

A. Encouraging the toddler to flush the toilet while still seated is incorrect. Some children may be startled by the flushing sound, which can create fear and resistance to toilet training. It is better to allow the child to stand before flushing if they show hesitation.

B. Having the toddler remain on the toilet for a minimum of 20 minutes is incorrect. Extended sitting can lead to discomfort and frustration, making the experience negative. Shorter, 5- to 10-minute sessions are more effective and developmentally appropriate.

C. Waking the toddler every 2 hours in the night to prevent bed-wetting is incorrect. Nighttime bladder control develops gradually, and disrupting sleep can be counterproductive. Instead, using protective bedding and encouraging toileting before bedtime is recommended.

D. Giving the toddler a sticker after each successful toileting attempt is correct. Positive reinforcement, such as stickers or praise, encourages consistency and motivation, which is particularly beneficial for children with cognitive impairments.

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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 administering pancrelipase to a child who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment?

Correct Answer is A

Explanation

A nurse is reinforcing teaching about toilet training with the guardians of a toddler who has a cognitive impairment. Which of the following instructions should the nurse include?

Correct Answer is D

Explanation

A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hr. PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this client care incident?

A nurse is monitoring a client's lower extremity following the placement of a cast earlier in the day. Which of the following findings should the nurse identify as manifestations of compartment syndrome? (Select all that apply.)

A nurse working in a rehabilitation unit is administering medications to two clients who have the same name. Which of the following identifiers should the nurse use to verify the identities of each client?

A nurse is contributing to the plan of care for a client who had prolonged exposure to cold weather and has a core body temperature of 32.5°C (90.5°F). Which of the following data is the priority for the nurse to monitor?

A nurse is supervising an assistive personnel (AP) obtain supplies for a client who is on seizure precautions. Which of the following materials should the AP place in the client's room?

A nurse is caring for a client who recently gave birth to her first child. The newborn is crying, and the client states, "I can't seem to do anything right. What should I do?" Which of the following responses should the nurse make?

A nurse is reinforcing teaching with a client who has a new diagnosis of COPD. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is preparing to administer ibuprofen solution 60 mg orally to a 7-month-old infant who is febrile. Available is ibuprofen 50 mg/1.25 mL. How many should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)