A nurse is preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take. (Placethem in the order of performance. Use all the steps.)

Open the innermost lower flap of the sterile kit while standing away from the sterile field.

Open each side flap of the sterile kit individually while pulling to the side.

Open the outside cover of the sterile kit and remove the dust cover.

Grasp the outermost flap of the sterile kit while opening away from the body.

Prepare a dry work surface above the waist level.

Answer and Explanation

The Correct Answer is E,C,D,B,A

Choice E Reason:

Preparing a dry work surface above the waist level. It's crucial to start by selecting and preparing an appropriate area for setting up the sterile field. This surface needs to be clean, dry, and above the waist level to maintain sterility and prevent contamination.

Choice C Reason:

Opening the outside cover of the sterile kit and remove the dust cover. This step involves opening the sterile kit without touching the inside contents to maintain sterility. Removing the outer cover exposes the sterile packaging and prepares for further steps.

Choice D Reason:

Grasping the outermost flap of the sterile kit while opening away from the body. By carefully opening the outermost flap, the nurse ensures that the sterile contents remain protected. Opening away from the body helps prevent accidental contamination from clothing or movements.

Choice B Reason:

Opening each side flap of the sterile kit individually while pulling to the side. Sequentially opening the side flaps maintains the sterile field and allows access to the inner contents without compromising sterility.

Choice A Reason:

Opening the innermost lower flap of the sterile kit while standing away from the sterile field. This final step involves accessing the innermost contents of the sterile kit while maintaining a safe distance to avoid accidental contamination. It ensures the contents within the sterile field remain protected until needed for the dressing change.

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Correct Answer is C

Explanation

Choice A Reason:

Adding diluent to the medication is not appropriate for ampules. Ampules typically contain a single-dose of medication in a liquid form.

Choice B Reason:

The ampule should be cleansed before opening to remove any potential contaminants. Once the ampule is opened, the inside of the ampule and the medication should be considered sterile, so there is no need to cleanse the tip after opening.

Choice C Reason:

A filter needle is used to prevent any glass particles from entering the syringe when drawing medication from an ampule, as ampules are made of glass that can sometimes break and leave shards.

Choice D Reason:

Injecting air into the ampule is not necessary. Ampules are designed to allow for the withdrawal of medication without the need to inject air.

A. "Call me so that I can help you change your position." B. "Try to close your eyes and get some sleep." C. "It is common for breathing to become more difficult as time goes on." D. "Therapy choices are limited for clients who do not want resuscitation."

Correct Answer is A

Explanation

Choice A Reason:

"Call me so that I can help you change your position." This response offers practical assistance and comfort to the client. Repositioning can sometimes alleviate discomfort associated with breathing difficulties, and the nurse can offer guidance or physical help to adjust the client's position for improved comfort.

Choice B Reason:

"Try to close your eyes and get some sleep." This response doesn't directly address the client's immediate concern about difficulty breathing and may not offer practical help.

Choice C Reason:

"It is common for breathing to become more difficult as time goes on." While this statement acknowledges the situation, it might not provide the client with actionable guidance or support on how to manage the difficulty in breathing.

Choice D Reason:

"Therapy choices are limited for clients who do not want resuscitation." This response might be interpreted as dismissive or unrelated to the client's immediate needs, focusing more on the DNR order rather than addressing the current concern about breathing difficulties.

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A nurse is preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take. (Placethem in the order of performance. Use all the steps.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?

Correct Answer is C

Explanation

A nurse is caring for a client who is terminally ill and has a do-not-resuscitate order on his medical record. The client asks, "What should I do if I have difficulty breathing?" Which of the following responses should the nurse make?

Correct Answer is A

Explanation

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