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.

Answer and Explanation

The Correct Answer is C

The correct answer is choice 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 not recommended. Spilled solution can compromise the sterility of the field, and covering it with gauze does not restore sterility. Instead, the nurse should avoid spilling solution to maintain the sterile field.

Choice B rationale:

Holding the irrigation solution bottle with the label facing away from the palm of the hand is incorrect. The correct technique is to hold the bottle with the label facing the palm. This prevents the label from getting wet and unreadable, ensuring that the nurse can always identify the solution correctly.

Choice C rationale:

Removing the cap and placing it sterile-side up on a clean surface is the correct action. This maintains the sterility of the cap, preventing contamination when it is replaced on the bottle. Ensuring the cap remains sterile is crucial for maintaining the sterility of 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 outside the sterile field to prevent contamination. The solution should be poured carefully to avoid splashing and compromising the sterile field.

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Correct Answer is C

Explanation

The correct answer is choice C. A client who was just given a glass of orange juice for a low blood glucose level.

This client should be assessed first because they are at risk of hypoglycemia, which is a medical emergency that can cause seizures, coma, or death if not treated promptly.

The nurse should check the client’s blood glucose level again and provide additional carbohydrates or glucose if needed.

Choice A is wrong because a client who is scheduled for a procedure in 1 hr is not in immediate danger and can be assessed later.

The nurse should verify the client’s consent, allergies, and vital signs before the procedure, but this is not a priority over a client with low blood glucose.

Choice B is wrong because a client who received a pain medication 30 min ago for postoperative pain is likely to have improved pain relief and does not need immediate assessment.

The nurse should monitor the client’s pain level, vital signs, and respiratory status periodically, but this is not a priority over a client with low blood glucose.

Choice D is wrong because a client who has 100 mL of fluid remaining in his IV bag is not in immediate danger and can be assessed later.

The nurse should change the IV bag when it is empty or nearly empty, but this is not a priority over a client with low blood glucose.

Normal blood glucose levels are between 70 to 100 mg/dL (3.9 to 5.5 mmol/L) when fasting, and less than 140 mg/dL (7.8 mmol/L) two hours after eating. A blood glucose level below 70 mg/dL (3.9 mmol/L) is considered hypoglycemia and requires immediate treatment. Orange juice is a source of simple carbohydrates that can raise blood glucose quickly, but it may not be enough to prevent hypoglycemia in some cases.

A. Would you like to speak to a spiritual advisor B. Do you need a prescription for an antianxiety medication C. Would you like to talk to a counselor about advance directives D. Do you need information on hospice care

Correct Answer is A

Explanation

The correct answer is choice A. “Would you like to speak to a spiritual advisor?”.

This statement shows respect for the client’s spirituality and offers support without imposing the nurse’s beliefs or values. Spirituality focuses on the significance and purpose of life and can help clients cope with depression and terminal illness.

Choice B is wrong because it implies that the client needs medication to deal with their feelings, which can be dismissive and insensitive.

Antianxiety medication may be appropriate for some clients, but it should not be the first option.

Choice C is wrong because it assumes that the client is ready to discuss advance directives, which may not be the case.

Advance directives are legal documents that specify the client’s wishes for end-of-life care, such as resuscitation, organ donation, or power of attorney.

The nurse should assess the client’s readiness and understanding before initiating this conversation.

Choice D is wrong because it suggests that the client is close to death and needs hospice care, which can be discouraging and frightening. Hospice care is an interdisciplinary team effort that provides palliative care for clients who have a terminal illness and a life expectancy of less than 6 months.

The nurse should explain the benefits of hospice care and obtain the client’s consent before making a referral.

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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?

Choice A rationale:

Choice B rationale:

Choice C rationale:

Choice D rationale:

Nursing Test Bank

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Correct Answer is C

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Correct Answer is A

Explanation

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