A nurse is preparing to complete a sterile dressing change for a client's wound. Which of the following actions should the nurse take first?

Open the flap on the sterile kit nearest to the nurse and place the flap on the work surface.

Open the side flap of the sterile kit, allowing it to lie flat on the work surface.

Open the outermost flap of the sterile kit away from the nurse's body

Apply sterile gloves.

Answer and Explanation

The Correct Answer is C

The correct answer is C. Open the outermost flap of the sterile kit away from the nurse's body.

Rationale: The nurse should open the outermost flap of the sterile kit away from their body first, as this will prevent contamination of their clothing or hands by touching any part of

the inside surface or contents of the kit. The nurse should then open each side flap by grasping only its outer edge and pulling it toward them. The nurse should then open the flap nearest to them by grasping only its outer edge and pulling it toward them. The nurse should then apply sterile gloves before touching any part of the inside surface or contents of the kit.

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Correct Answer is A

Explanation

The correct answer is A.

Ensure the client swallows each dose of medication. A client who recently attempted suicide is at high risk of another suicide attempt and needs closemonitoring and supervision. The nurse should ensure that the client swallows each dose of medication to prevent hoarding or overdosing on pills. The nurse should also remove any potential means of self-harm from the client's room, such as sharp objects, belts, cords, or cologne that contains alcohol. The nurse should keep the client's door open or use a window to observe them at all times, not just every 2 hours.

A. Identify the client by using one identifier before giving the medication. B. Document medication administration prior to administering medication. C. Administer time-critical medication 60 min before or after the scheduled time. D. Verify the medication three times with the medication administration record.

Correct Answer is D

Explanation

The correct answer is D.

Verify the medication three times with the medication administration record. The nurse should follow the six rights of medication administration: right client, right drug, right dose, right route, right time, and right documentation. To ensure the right drug and dose, the nurse should check the medication label against the medication administration record (MAR) three times: before removing the medication from the storage area, before preparing or measuring the medication, and before administering the medication to the client.

The nurse should also use two identifiers (such as name and date of birth) to verify the right client. The nurse should document medication administration after giving the medication, not before, to avoid errors and ensure accuracy. The nurse should administer time-critical medications within 30 minutes before or after the scheduled time, not 60 minutes.

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A nurse is preparing to complete a sterile dressing change for a client's wound. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who recently attempted suicide. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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