A nurse is setting up a sterile field to perform wound irrigation for a client.
Which of the following actions should the nurse take when pouring the sterile solution?
Place sterile gauze over areas of spilled solution within the sterile field.
Hold the irrigation solution bottle with the label facing away from the palm of the hand.
Remove the cap and place it sterile-side up on a clean surface.
Hold the bottle in the center of the sterile field when pouring the solution.
The Correct Answer is C
The correct answer is c. Remove the cap and place it sterile-side up on a clean surface.
Choice A rationale:
Placing sterile gauze over areas of spilled solution within the sterile field is incorrect. If solution is spilled within the sterile field, the entire field should be considered contaminated and a new sterile field should be set up
Choice B rationale:
Holding the irrigation solution bottle with the label facing away from the palm of the hand is incorrect. The label should face the palm of the hand to avoid contamination of the sterile field
Choice C rationale:
Removing the cap and placing it sterile-side up on a clean surface is correct. This ensures that the sterile side of the cap remains sterile and can be used to recap the bottle after pouring the solution
Choice D rationale:
Holding the bottle in the center of the sterile field when pouring the solution is incorrect. The bottle should be held over the edge of the sterile field to avoid contamination of the field if solution spills
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A client who is experiencing a panic attack has a very high level of anxiety and a diminished ability to focus. The nurse should stay with the client and remain calm and reassuring during the panic attack. This can help the client feel safe and supported, and reduce the intensity of the anxiety.
Choice A is wrong because atomoxetine is not an anti-anxiety medication, but a selective norepinephrine reuptake inhibitor (SNRI) used to treat attention deficit hyperactivity disorder (ADHD). It has no effect on reducing anxiety and can cause side effects such as insomnia, nausea, and increased blood pressure.
Choice B is wrong because encouraging the client to watch television is not a therapeutic intervention for a panic attack.
Watching television can increase the stimuli in the client’s environment, which can worsen anxiety.
The nurse should maintain an environment with low stimulation for the client experiencing a panic attack. Dim lighting, few people, and minimal distractions can assist the nurse to decrease the client’s level of anxiety.
Choice C is wrong because teaching the client how to meditate is not appropriate during a panic attack.
Meditation is a relaxation technique that can be helpful for preventing or reducing anxiety, but it requires concentration and focus, which are impaired in a panic attack. The nurse should teach the client how to meditate when the client is calm and receptive, not when the client is in crisis.
Correct Answer is A
Explanation
This is because boundaries can help the client and family to respect each other’s roles, needs, and preferences, and to avoid role confusion, resentment, or guilt. Boundaries can also promote independence and self-care for the client, as well as prevent caregiver burnout for the family.
Choice B is wrong because minimizing open discussion regarding the changes can lead to misunderstanding, frustration, or isolation. The client and family should communicate openly and honestly about their feelings, expectations, and challenges, and seek support when needed.
Choice C is wrong because authoritative communication from the adult child can create a power imbalance, undermine the client’s autonomy and dignity, or cause conflict or resistance. The client and family should use respectful and collaborative communication, and involve the client in decision-making as much as possible.
Choice D is wrong because decreasing socialization with extended relatives can reduce the client and family’s support network, increase their stress or loneliness, or limit their opportunities for meaningful activities. The client and family should maintain contact with their relatives and friends, and participate in social or recreational activities that they enjoy.
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