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) Phlebitis: The presence of redness and warmth around the peripheral catheter insertion site is indicative of phlebitis, which is inflammation of the vein. This condition can result from mechanical irritation, chemical irritation from the infusion, or infection. It is crucial to monitor and document these findings promptly.

B) Extravasation: This occurs when intravenous (IV) fluids or medications leak into the surrounding tissue, causing tissue damage. Symptoms typically include pain, swelling, and possible blistering, rather than just redness and warmth.

C) Infiltration: This refers to the unintentional infusion of fluid into the surrounding tissue due to the catheter becoming dislodged or puncturing the vein. It is characterized by swelling, coolness, and tenderness at the site rather than warmth and redness.

D) Circulatory overload: This condition results from excessive fluid volume in the circulatory system, leading to symptoms such as shortness of breath, hypertension, and peripheral edema. It is not associated with localized redness and warmth at the catheter site.

A. Place the client in Trendelenburg position. B. Apply fundal pressure. C. Loosely wrap the cord with petroleum gauze. D. Evaluate uterine ton

Correct Answer is A

Explanation

A. Place the client in Trendelenburg position: This position helps relieve pressure on the umbilical cord, potentially improving blood flow to the fetus. It is an appropriate immediate intervention for a prolapsed cord.

B. Apply fundal pressure: This is contraindicated in cases of cord prolapse as it can exacerbate the situation by pushing the presenting part further down and increasing pressure on the cord.

C. Loosely wrap the cord with petroleum gauze: While protecting the cord is important, simply wrapping it does not address the immediate need to relieve pressure and restore blood flow to the fetus.

D. Evaluate uterine tone: While assessing uterine tone is important during labor, the immediate priority when a prolapsed cord is noted is to relieve pressure on the cord to prevent fetal compromise. Therefore, this step should not be the first action taken.

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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 assessing the peripheral catheter insertion site of a client who is receiving an infusion. The nurse notices redness and warmth to the touch around the insertion site. The nurse should document the finding as which of the following complications?

Correct Answer is A

Explanation

A nurse is caring for a client who is in labor and notes that the umbilical cord is prolapsed. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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