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?

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

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.

Answer and Explanation

The Correct Answer is D

A: The sterile field should be set up at or above waist level to prevent contamination from higher surfaces, not below.
B: The outer edge (about 2.5 cm or 1 inch) of the sterile field is considered non-sterile, so placing the sterile dressing close to the edge risks contamination.

C: The outermost flap of the sterile kit should be opened away from the body to avoid reaching over the sterile field, which could lead to contamination.
D: The cap should be placed sterile side up to maintain its sterility if it needs to be reapplied to the solution bottle.

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Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}

Explanation

Serotonin syndrome is a serious drug reaction that results from having too much serotonin in the body. Serotonin is a chemical that plays a role in mood, sleep, appetite and other functions. Some medications, especially antidepressants, can increase serotonin levels and cause serotonin syndrome. The client is taking paroxetine, which is a type of antidepressant called a selective serotonin reuptake inhibitor (SSRI). SSRIs work by blocking the reabsorption of serotonin in the brain, making more serotonin available.

Paroxetine can cause serotonin syndrome if taken at high doses, in combination with

other serotonergic drugs, or if abruptly stopped. The client’s symptoms of restlessness, abdominal pain, disorientation and fever are consistent with serotonin syndrome. Other possible symptoms include agitation, confusion, rapid heart rate, high blood pressure, dilated pupils, muscle twitching, rigidity, sweating and shivering. Severe serotonin syndrome can lead to seizures, coma and death. The client should stop taking paroxetine and seek immediate medical attention. Serotonin syndrome can be treated with supportive care and medications that reduce serotonin levels or block its effects. The client may need to switch to a different antidepressant or adjust the dosage under the guidance of their provider.

A. Recording the client's progress in the nurses' notes B. Noting changes in the treatment plan in the client's medical record C. Having interdisciplinary team meetings for the client on a regular basis D. Posting swallowing precautions at the head of the client's bed

Correct Answer is C

Explanation

A. While important for documenting the client's progress, this choice does not directly promote communication among staff members.
B. While essential for maintaining accurate records, this action does not directly facilitate communication among staff.
C. Interdisciplinary team meetings allow healthcare professionals from different disciplines to collaborate, share information, and develop comprehensive care plans tailored to the client's needs. This promotes effective communication among staff caring for the client with expressive aphasia and right hemiparesis.
D. While important for the client's safety, this action does not address the need for ongoing communication and collaboration among staff members.

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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 caring for a client at a clinic. Exhibits Complete the following sentence by using the lists of options. The client is at risk for developing dropdown due to dropdown.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}

Explanation

A nurse is caring for a client who is experiencing expressive aphasia and right hemiparesis following a stroke. Which of the following actions by the nurse best promotes communication among staff caring for the client?

Correct Answer is C

Explanation

A nurse is caring for a client who presents to the emergency department. Exhibits A nurse is reviewing the client's record. Which of the following client findings indicate the need for further evaluation? Select all that apply.

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