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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason
Re-evaluate the client for an ET cuff leak is not appropriate. While an ET cuff leak could contribute to respiratory distress, the immediate concern is the high-pressure alarm, which indicates increased resistance to airflow. The nurse should address the alarm first and then assess for other potential causes, including an ET cuff leak.
Choice B reason:
Option B: Assess for disconnected tubing is not appropriate. A disconnected tubing is also a potential cause of the high-pressure alarm. However, before checking for disconnected tubing, the nurse should first deliver manual breaths with a resuscitation bag to provide the client with adequate ventilation.
Choice C reason:
Decrease the ventilator flow rate is not appropriate. Decreasing the ventilator flow rate might not be the appropriate action in this situation, as the high-pressure alarm indicates increased resistance, which might require increased flow to overcome. Additionally, the nurse should not delay taking immediate action by adjusting ventilator settings without knowing the specific cause of the high-pressure alarm.
Choice D reason:
When the high-pressure alarm is beeping, and the client is experiencing respiratory distress, it indicates that there is an increased resistance to airflow within the ventilator circuit or the client's airway. This can be a life-threatening situation, and immediate action is required.
Correct Answer is A
Explanation
Choice A reason:
Urine specific gravity is the measurement of the concentration of solutes in urine and is an important indicator of the client's hydration status and kidney function. A specific gravity of 1.035 is relatively high, suggesting concentrated urine. High urine specific gravity can be a sign of dehydration or other kidney-related issues.
Reporting this finding to the provider is crucial because it could indicate potential problems with the client's fluid balance and kidney function. The provider may need to assess further, conduct additional tests, or initiate appropriate interventions to address the client's hydration and renal status.
Choice B reason:
Prealbumin: A prealbumin level of 25 mg/dL is within the normal range (usually 15-35 mg/dL) and may not require immediate reporting to the provider. Prealbumin is used to assess nutritional status, and this result suggests that the client's nutritional status is within the normal range.
Choice C reason:
Temperature: The provided information does not include any data about the client's temperature, and there are no signs of infection mentioned. Unless there are specific signs or symptoms of fever or infection, reporting the temperature is not necessary based on the given data.
Choice D reason
Bowel sounds: The provided information does not include any data about the client's bowel sounds, and there are no indications of gastrointestinal issues or abnormalities. Bowel sounds may not be relevant to report unless there are specific symptoms or signs of GI disturbances.
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