A nurse is setting up a sterile field before performing a dressing change on a client who is postoperative. Which of the following actions should the nurse plan to take to maintain the sterile field? (Select all that apply.)

Select a work surface at the nurse's waist level.

Open the first flap of the sterile package toward the nurse's body.

Grasp 2.5 cm (1 in) of the outer edge to open the surgical wrap.

Place & surgical pack with a sterile drape on the work surface.

Apply sterile gloves before opening the pack

Answer and Explanation

Correct Answer : B,D

B. Open the first flap of the sterile package toward the nurse's body: When opening a sterile package, the nurse should open the first flap away from their body to prevent potential contamination from falling particles. This action helps maintain the sterility of the contents inside.

D. Place a surgical pack with a sterile drape on the work surface: Placing the surgical pack with a sterile drape on the work surface ensures that the sterile field is properly established. The sterile drape provides a clean and sterile area for the nurse to perform the dressing change.

Incorrect answers:

A. Select a work surface at the nurse's waist level: While it is important to select a work surface at an appropriate height for the nurse's comfort and ergonomics, the height of the work surface does not directly affect the maintenance of a sterile field.

C. Grasp 2.5 cm (1 in) of the outer edge to open the surgical wrap: When opening a sterile package, the nurse should grasp the inner edge of the sterile wrap to maintain the sterility of the contents. Grasping the outer edge can potentially lead to contamination of the sterile field.

E. Apply sterile gloves before opening the pack: Sterile gloves should be applied after the sterile field is established. Opening the sterile pack and setting up the sterile field should be done with clean (non-sterile) hands to avoid contaminating the contents. Once the sterile field is set up, the nurse can don sterile gloves before actually touching the sterile items.

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Correct Answer is A

Explanation

Choice A Reason:

"I can drink vegetable juice with a meal."

Limiting sodium intake is a crucial part of managing heart failure, as excess sodium can lead to fluid retention and exacerbation of symptoms. Among the options provided, drinking vegetable juice with a meal is the one that suggests the client understands the need to limit sodium intake. Fresh vegetable juice typically has lower sodium content compared to other options, and incorporating it into meals can help the client manage their sodium intake.

Choice B Reason:

"I can have mayonnaise on my sandwiches." - Mayonnaise is often high in sodium and is not typically recommended in a low-sodium diet.

Choice C Reason:

"I can season my foods with garlic and onion salts." - Garlic and onion salts are often high in sodium. It's better to use fresh herbs and spices for seasoning.

Choice D Reason:

"I can have a frozen fruit juice bar for dessert." - Frozen fruit juice bars might contain added sugars or high sodium content. It's important to check the nutrition label for sodium content before consuming such items.

A. To prevent alveolar collapse B. To provide positive airway pressure during inspiration C. To deliver a set tidal volume D. To control the rate of ventilations

Correct Answer is A

Explanation

Choice A Reason:

To prevent alveolar collapse is the correct answer. Positive end-expiratory pressure (PEEP) is used in mechanical ventilation to prevent alveolar collapse during expiration. Alveolar collapse, also known as atelectasis, can occur when the alveoli (air sacs in the lungs) collapse and don't fully re-inflate during the breathing cycle. This can lead to impaired gas exchange and decreased lung compliance. By applying positive pressure to the airways at the end of expiration, PEEP helps keep the alveoli open and improves oxygenation by maintaining lung volume.

Choice B Reason:

Positive airway pressure during inspiration is typically provided by the inspiratory pressure support, not by PEEP.

Choice C Reason:

Tidal volume refers to the amount of air moved into and out of the lungs with each breath. It is not the purpose of PEEP.

Choice D Reason:

Controlling the rate of ventilations is usually achieved by adjusting the ventilator settings for respiratory rate, not by using PEEP.

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A nurse is setting up a sterile field before performing a dressing change on a client who is postoperative. Which of the following actions should the nurse plan to take to maintain the sterile field? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who has heart failure and instructs him to limit sodium intake to 2 g per day. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

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Correct Answer is A

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