A nurse is setting up a sterile field in a client's room.
Which of the following actions should the nurse take?

Placing the cap of a sterile solution on a clean surface with the inside facing down.

Placing a sterile instrument within 1.3 cm (0.5 in) of the edge of the sterile field.

Opening the top flap of the sterile tray package away from their body.

Dropping sterile objects onto the field from a height of 5 cm (2 in). .

Answer and Explanation

The Correct Answer is C

Choice A rationale

Placing the cap of a sterile solution on a clean surface with the inside facing down can contaminate the cap. It should be placed with the inside facing up to maintain sterility.

Choice B rationale

Placing a sterile instrument within 1.3 cm (0.5 in) of the edge of the sterile field risks contamination, as the edges are considered non-sterile. Instruments should be placed well within the sterile field.

Choice C rationale

Opening the top flap of the sterile tray package away from their body ensures that the sterile contents are not contaminated by the nurse's clothing or body, maintaining the sterility of the field.

Choice D rationale

Dropping sterile objects onto the field from a height of 5 cm (2 in) can cause contamination due to the potential for the objects to fall outside the sterile field. Objects should be placed gently onto the field without dropping them.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale

This statement indicates that the client understands advance directives allow them to make decisions about their care while they are still capable. This reflects the purpose of advance directives, which is to respect and uphold the client’s autonomy and choices regarding their medical care.

Choice B rationale

This statement is incorrect because clients can change their advance directives or living will at any time. The purpose of these documents is to provide flexibility and ensure that the client's current wishes are followed.

Choice C rationale

This statement is incorrect. Once a living will is signed and witnessed or notarized, it becomes legally binding without a waiting period. The delay mentioned here is not a part of the advance directive process.

Choice D rationale

This statement is not accurate. A living will usually includes decisions about life support, and a separate consent form is not typically needed for those decisions. The client’s wishes regarding life support would be documented in the living will itself.

A. Document the refusal in the client's medical record. B. Return the medication to the medication cabinet. C. Inform the client of the potential consequences of their refusal. D. Notify the provider of the client's refusal.

Correct Answer is C

Explanation

Choice A rationale

Documenting the refusal in the client's medical record is important for legal and clinical reasons, ensuring there's a record of the client's decision and the nurse's response. However, it doesn't address the client's immediate concerns or needs.

Choice B rationale

Returning the medication to the medication cabinet is a necessary step to ensure medication safety and avoid accidental administration. Yet, it does not address the client's reasons for refusal or the potential risks involved.

Choice C rationale

The nurse’s first action should be to provide client education about the importance of taking the medication and the potential consequences of refusal (e.g., increased blood pressure, risk of stroke or heart attack). Addressing the client’s concerns about side effects can encourage adherence or lead to an alternative treatment plan.Client autonomy is respected, but ensuring informed refusal is part of the nurse’s role.

Choice D rationale

The provider should be informed, but only after the nurse has attempted to educate and address the client’s concerns. The provider may adjust the prescription if side effects are problematic.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is setting up a sterile field in a client's room.Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about advance directives with a client who has terminal colorectal cancer.Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is caring for a client who refuses their morning dose of antihypertensive medication. The client tells the nurse, "I'm not going to take this medication because it makes me sick and dizzy.”. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is reviewing the laboratory reports of four clients.Which of the following clients should the nurse expect to have a positive fecal occult blood test?

A home health nurse is visiting a client who has advanced Alzheimer's disease. The client's partner states, "I miss being able to go places with my friends.”. Which of the following is an appropriate response by the nurse?

A nurse is caring for a group of clients.For which of the following situations should the nurse complete an incident report? (Select all that apply.)

A nurse is assisting with scoliosis screenings for students at a public school.Which of the following findings should the nurse recognize as an indication of scoliosis?

A nurse is reinforcing teaching with a client about how to collect a stool specimen.Which of the following instructions should the nurse include?

A nurse is caring for an older adult client who has a hearing aid.Which of the following actions should the nurse take when the client reports hearing a whistling sound from the hearing aid?

A nurse is participating in a group discussion about complicated grief associated with loss.Which of the following should the nurse identify as an example of exaggerated grief?

A nurse is collecting a urine specimen for culture and sensitivity from a client who has an indwelling urinary catheter.Which of the following actions should the nurse take?

A nurse is setting up a sterile field in a client's room.
Which of the following actions should the nurse take?