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 C

Explanation

The correct answer is choice C. Clean the stoma using an inward to outward circular motion.

Choice A rationale:

Cleansing the inner cannula with isopropyl alcohol is not recommended because it can be irritating to the mucosa. Instead, the inner cannula should be cleaned with sterile saline or a prescribed solution.

Choice B rationale:

Preparing sterile supplies after removing the inner cannula is not the correct sequence. Sterile supplies should be prepared before starting the procedure to maintain sterility and efficiency.

Choice C rationale:

Cleaning the stoma using an inward to outward circular motion is correct because it helps to prevent the spread of microorganisms from the outer skin to the stoma site, reducing the risk of infection.

Choice D rationale:

Ensuring at least three finger widths of space under tracheostomy ties is incorrect. The correct practice is to ensure that only one to two finger widths can fit under the tracheostomy ties to ensure they are secure but not too tight.

A. Administer an oral antiepileptic medication B. Place the child in a supine position. C. Check the child for oral injuries. D. Offer the child sips of clear fluids.

Correct Answer is C

Explanation

The correct answer is C.

Check the child for oral injuries. The rationale is that during a tonic-clonic seizure, the child may bite their tongue, cheek or lips and cause bleeding or damage to their oral tissues. The nurse should inspect the child's mouth for any injuries and provide appropriate care.

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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 preparing to provide tracheostomy care for a client. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

A nurse is caring for a 3-year-old child immediately following a tonic-clonic seizure. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is assisting with a prenatal examination of a client who is at 8 weeks of gestation.The nurse notes that the client's vagina and vulva are a purplish color. The nurse should document this finding as which of the following?

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A nurse is reinforcing teaching with a client who has primary open-angle glaucoma and a new prescription for timolol eye drops. Which of the following statements indicates an understanding of the teaching?

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?

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