A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field?

Place the sterile dressing within 1.25 cm (0.5 in) of the edge of the sterile field.

Open the outermost flap of the sterile kit toward the body.

Place the cap from the solution sterile side up on a clean surface.

Set up the sterile field 5 cm (2 in) below waist level.

Answer and Explanation

The Correct Answer is C

A. Place the sterile dressing within 1.25 cm (0.5 in) of the edge of the sterile field: This action is not appropriate, as sterile items should be placed at least 2.5 cm (1 in) away from the edge of the sterile field to maintain sterility and prevent contamination.

B. Open the outermost flap of the sterile kit toward the body: The correct practice is to open the outermost flap away from the body. This technique helps prevent any contaminants from the nurse's clothing or body from falling into the sterile field.

C. Place the cap from the solution sterile side up on a clean surface: This is the correct action. By placing the cap sterile side up, the nurse minimizes the risk of contamination to the sterile solution and maintains the integrity of the sterile field.

D. Set up the sterile field 5 cm (2 in) below waist level: Setting up a sterile field below waist level increases the risk of contamination, as it may come into contact with non-sterile surfaces. The sterile field should be set up at waist level or higher to maintain sterility.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A) Administer 1 L dextrose 5% in water IV bolus prior to the procedure: Administering a large volume IV bolus is generally unnecessary before a paracentesis. It can lead to abdominal distension and discomfort, potentially complicating the procedure. Fluid management should be carefully considered based on the client’s condition rather than a standard bolus.

B) Initiate NPO status 4 hr prior to the procedure: Paracentesis typically does not require NPO status unless sedation is planned, which is uncommon. Keeping the client NPO can cause unnecessary discomfort and does not align with standard pre-procedural care for a paracentesis, which usually allows for regular oral intake.

C) Position the client over an overbed table prior to the procedure: While positioning is crucial for comfort and access, clients are generally positioned sitting at the edge of the bed or in a semi-Fowler's position. An overbed table may not provide adequate support and could lead to discomfort or complications during the procedure.

D) Instruct the client to empty her bladder prior to the procedure: This action is important as it helps reduce the risk of bladder injury during the paracentesis and minimizes discomfort. An empty bladder allows for better access to the abdominal cavity, indicating that the nurse understands the necessary preparations for the procedure.

A. "Limit the time your infant feeds to 10 minutes on each breast." B. "Supplement breastfeeding with water every 12 hours." C. "Begin each feeding using the same breast." D. "Offer your infant the breast when he shows signs of hunger."

Correct Answer is D

Explanation

A) "Limit the time your infant feeds to 10 minutes on each breast.": Limiting feeding time can be detrimental, as infants often need varying lengths of time to effectively nurse. It's essential to allow the infant to feed as long as they need to ensure adequate milk intake and to stimulate milk production.

B) "Supplement breastfeeding with water every 12 hours.": Breastfed infants typically do not need supplemental water in the first six months of life, as breast milk provides all necessary hydration and nutrients. Offering water can fill the infant's stomach and reduce breastfeeding frequency, impacting nutrition.

C) "Begin each feeding using the same breast.": It's common to start with one breast and then offer the second breast if the infant is still hungry. However, alternating which breast to start with at each feeding can help maintain an even milk supply and prevent engorgement.

D) "Offer your infant the breast when he shows signs of hunger.": This is the most appropriate recommendation. Recognizing and responding to hunger cues—such as rooting, smacking lips, or increased alertness—promotes successful breastfeeding and ensures that the infant is receiving adequate nutrition.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is scheduled to have a paracentesis. Which of the following actions should the nurse include in the plan of care?

Correct Answer is D

Explanation

A nurse is providing discharge teaching to a new parent about breastfeeding her infant. Which of the following statements should the nurse make?

Correct Answer is D

Explanation

A school nurse is performing scoliosis screenings. The nurse should recognize which of the following clinical manifestations as an indication of scoliosis?

A nurse is preparing to administer an IV medication to a client and accidently punctures the IV bag, causing the medication to leak on the counter. Which of the following medications requires the nurse to follow facility procedures in the safe handling of a biohazardous material spill?

A nurse is teaching a client who plans to begin following vegan dietary guidelines. Which of the following information should the nurse include?

A nurse is preparing to catheterize a toddler for a urine culture. Which of the following is an appropriate action for the nurse to take?

A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding?

A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make?

A nurse is caring for a client who speaks a different language than the nurse and is using an interpreter. Which of the following actions should the nurse take when working with the interpreter?

A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine?