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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Reinforcing discharge teaching with the client's partner who speaks the languages of both the client and the nurse is not appropriate. While involving the client's partner may be helpful, it's essential to ensure that the information is accurately and comprehensively translated. Relying solely on the partner may not guarantee clear communication.
Choice B Reason:
Asking a nurse from another unit who speaks the same language as the client to reinforce the discharge teaching is inappropriate. While this option might be helpful if such a nurse is available, it may not always be practical to find a nurse who speaks the specific language required. Additionally, the nurse's expertise in the discharge instructions may vary.
Choice C Reason:
Requesting that a medical interpreter assist with translating the discharge teaching for the client is appropriate. Using a medical interpreter ensures accurate and clear communication, reducing the risk of misunderstandings. It promotes effective communication between the nurse and the client, ensuring that important information about post-discharge care is accurately conveyed.
Choice D Reason:
Using nonverbal communication with gestures to reinforce discharge teaching with the client is inappropriate. While nonverbal communication and gestures can be supplementary, relying solely on them may not convey detailed information accurately. Important details about medications, follow-up appointments, and self-care may be lost without verbal communication.
Correct Answer is D
Explanation
Choice A Reason:
Muscle weakness is incorrect. Muscle weakness can be a symptom of hyperkalemia (elevated potassium levels). However, it is not the most urgent symptom, and the provider should be informed to address the underlying cause.
Choice B Reason:
Paresthesias is incorrect. Paresthesias (tingling or numbness) can also occur with hyperkalemia. While important to assess, it may not be the most urgent symptom requiring immediate attention.
Choice C Reason:
Abdominal cramps is incorrect. Abdominal cramps can be associated with hyperkalemia, but they are not the most critical symptom. It's essential to address the underlying cause, but it may not require immediate intervention compared to other symptoms.
Choice D Reason:
Palpitations is correct. Palpitations are a concerning symptom, especially in the context of hyperkalemia. Elevated potassium levels can lead to cardiac arrhythmias, and palpitations may be indicative of serious cardiac complications. This is a critical finding that requires immediate attention from the healthcare provider.
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