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 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. Limit oral feedings to 30 min in length.
This is because infants with heart failure have difficulty feeding and may become exhausted or dyspneic during prolonged feedings. By limiting the feeding time, the nurse can reduce the energy expenditure and caloric needs of the infant.
Choice B is wrong because weighing the infant every other day is not enough to monitor the fluid status and nutritional intake of the infant. The nurse should weigh the infant daily at the same time using the same scale.
Choice C is wrong because placing the infant in the prone position can compromise the respiratory function and increase the risk of sudden infant death syndrome (SIDS). The nurse should place the infant in a semi-Fowler’s position to facilitate breathing and decrease venous return.
Choice D is wrong because checking the infant’s oxygen saturation every 6 hr is not frequent enough to detect hypoxia or cyanosis. The nurse should monitor the oxygen saturation continuously or at least every 2 hr.
Correct Answer is C
Explanation
Enoxaparin is a blood thinner that helps prevent the formation of blood clots in people who have certain medical conditions or who are undergoing certain procedures. Enoxaparin can increase the risk of bleeding, especially if taken with other medications that affect blood clotting, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin.
Therefore, the nurse should instruct the client to avoid taking pain relievers such as naproxen sodium (choice A), ibuprofen (choice B), or aspirin (choice D) while on enoxaparin. These pain relievers can make the client more likely to bleed when on enoxaparin. Acetaminophen (choice C) is a pain reliever that does not affect blood clotting and can be taken safely with enoxaparin. However, the client should follow the directions on the box to make sure they do not take more than the recommended amount of acetaminophen, as it can cause liver damage in high doses.
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