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 B
Explanation
Explanation: The nurse should respect and support the client's decision to stop dialysis treatment, as it is an expression of autonomy and self-determination. Discussing alternative treatment methods, asking the facility chaplain to visit, and telling the client she should discuss this decision with her family are all actions that may imply that the nurse does not accept or respect the client's decision.
Correct Answer is B
Explanation
The correct answer is B.
Stop the infusion. The nurse should stop the infusion immediately to prevent further fluid accumulation and tissue damage. This is a priority action accordingto the ABCDE principle, which guides nurses to prioritize airway, breathing, circulation, disability, and exposure issues. Infiltration is a complication of IV therapy that occurs when fluid leaks into the surrounding tissue due to dislodgment or puncture of the catheter. The signs and symptoms of infiltration include edema, coolness, pallor, pain, and decreased flow rate at the insertion site.
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