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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Splitting behavior, where the client views people and situations as either all good or all bad, is more characteristic of borderline personality disorder rather than histrionic personality disorder.
B. Emotional lability, characterized by rapid shifts in mood, is not a primary feature of histrionic personality disorder.
C. Unexpressive affect, or a lack of emotional expression, is not a typical feature of histrionic personality disorder, which often presents with exaggerated and dramatic emotional displays.
D. Self-centered behavior, including attention-seeking and dramatic behavior to gain approval or admiration from others, is a hallmark feature of histrionic personality disorder.
Correct Answer is B
Explanation
A. Providing a cooling blanket may help reduce fever associated with a thyroid storm but is not the priority over monitoring the cardiac rhythm.
B. In a thyroid storm, the client is at risk for severe cardiovascular complications, including tachycardia, arrhythmias, and heart failure. Therefore, the nurse's priority action is to monitor the client's cardiac rhythm continuously to detect any abnormalities promptly and intervene as needed.
C. Administering 0.9% sodium chloride IV may be necessary to maintain fluid balance, but it's not the priority over cardiac monitoring.
D. Obtaining the client's blood glucose may be relevant but is not the priority in the acute management of a thyroid storm.
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