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.

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 B

Explanation

The correct answer is choice B. Isolate the client from staff who are pregnant. Choice A rationale: Aspirin should not be administered to children or adolescents with viral infections like rubella due to the risk of Reye's syndrome, a potentially fatal condition that causes liver and brain damage. Choice B rationale: Rubella (German measles) is particularly dangerous for pregnant women because it can cause congenital rubella syndrome in the fetus, leading to severe birth defects. Therefore, isolating the client from pregnant staff is crucial to prevent exposure. Choice C rationale: Airborne precautions are not necessary for rubella. Rubella is transmitted through respiratory droplets, so droplet precautions, not airborne precautions, are appropriate. Choice D rationale: Koplik spots are associated with measles (rubeola), not rubella. Therefore, monitoring for Koplik spots is not relevant for a client with rubella.

A. Swaddle the newborn with his legs extended. B. Administer naloxone to the newborn C. Maintain eye contact with the newborn during feedings D. Minimize noise in the newborn’s environment

Correct Answer is D

Explanation

The correct answer is choice D. Minimize noise in the newborn’s environment.

This is because neonatal abstinence syndrome (NAS) is a condition that affects newborns who are exposed to opioids or other addictive substances in the womb. These substances can cause withdrawal symptoms in the newborns, such as excessive crying, tremors, vomiting, diarrhea, and seizures.

Minimizing noise and other stimuli can help calm the newborn and reduce stress.

Choice A is wrong because swaddling the newborn with his legs extended can increase muscle tension and discomfort. Swaddling should be done with the legs flexed and hips abducted to prevent hip dysplasia.

Choice B is wrong because administering naloxone to the newborn can cause severe withdrawal symptoms and respiratory depression. Naloxone is an opioid antagonist that reverses the effects of opioids, but it is not recommended for newborns with NAS unless they have life-threatening respiratory depression.

Choice C is wrong because maintaining eye contact with the newborn during feedings can overstimulate the newborn and cause agitation. Eye contact should be avoided or limited during feedings for newborns with NAS.

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 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

Naxlex Comprehensive Predictor Exams

A nurse is admitting an adolescent who has rubella. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan?

Correct Answer is D

Explanation

A nurse is instructing a school-age child who has asthma about the use of a peak expiratory flow meter. Which of the following instructions should the nurse include in the teaching?

A nurse is providing teaching to a client who has a new prescription for enoxaparin. Which of the following medications for pain relief should the nurse include in the teaching that can be taken concurrently with enoxaparin?

A nurse is reviewing the laboratory data of a client who received 2 units of packed RBCs. Which of the following laboratory findings should the nurse expect following the transfusion?

A nurse is preparing to administer a medication that is available in a glass ampule. Which of the following actions should the nurse plan to take?

A nurse is assessing a client who is taking haloperidol and is experiencing pseudoparkinsonism. Which of the following findings should the nurse document as a manifestation of pseudoparkinsonism?

A nurse is caring for a client who is admitted to the medical-surgical unit. Client reports, "I'm bloated and my stomach hurts." Exhibits The nurse reviews the client's laboratory findings and vital signs. Select the 5 findings that require immediate follow-up.

A nurse is caring for a client who has a placenta previa. Which of the following findings should the nurse expect?

A nurse in an emergency department is caring for a client. Exhibits A nurse in an outpatient orthopedic clinic is caring for the client six weeks following surgical repair of a fractured radius. Which of the following information provided by the client indicates improvement? Select all that apply.