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.

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Correct Answer is A

Explanation

A. Provide the client with large-handled eating utensils: This intervention is beneficial for clients with multiple sclerosis, as it can help improve their grip and ease the process of eating. This is particularly important for clients who may experience weakness or coordination issues.

B. Touch the client's arm before beginning to speak: While this may be a considerate gesture for individuals with hearing impairments, it is not specifically targeted to address barriers faced by clients with multiple sclerosis, who may have visual or cognitive challenges.

C. Establish alternatives to verbal conversation: While offering alternative communication methods can be helpful, the primary barriers for many clients with multiple sclerosis often relate to physical function rather than communication alone.

D. Use the numbers on a clock to describe the position of food on the client's plate: This technique can be useful for clients with visual impairments, but it does not directly address the motor and coordination challenges often faced by clients with multiple sclerosis in daily tasks like eating.

A. "You should administer the medication at bedtime." B. "You should administer the medication after breakfast." C. "Your child should avoid excess sodium intake." D. "Your child should avoid foods containing tyramine."

Correct Answer is B

Explanation

A) Administering the medication at bedtime is not advisable because methylphenidate is a stimulant that can cause insomnia. It's typically recommended to give it in the morning or after breakfast to help manage symptoms during the day while minimizing sleep disturbances.

B) Administering the medication after breakfast is the best practice. Taking methylphenidate with food can help reduce gastrointestinal side effects and improve the medication's effectiveness throughout the school day. This timing also aligns with the medication's action profile to support focus and attention during daytime activities.

C) While monitoring sodium intake can be important for overall health, there is no specific requirement for children taking methylphenidate to avoid excess sodium. Instead, a balanced diet is generally encouraged, and any dietary changes should be discussed with a healthcare provider.

D) Foods containing tyramine are typically associated with monoamine oxidase inhibitors (MAOIs) and are not specifically a concern with methylphenidate. Therefore, advising avoidance of tyramine-rich foods is not relevant in this context, and the focus should be on proper medication management and monitoring for side effects.

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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 contributing to the plan of care for a client who has multiple sclerosis. The nurse should recommend including which of the following interventions in the plan of care to assist the client in overcoming barriers related to this condition?

Correct Answer is A

Explanation

A nurse is teaching a parent of a school-age child who is to begin a daily dose of methylphenidate. Which of the following should the nurse include in the teaching?

Correct Answer is B

Explanation

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