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: “We can review some information to help you select a safe alternative practitioner.” This statement shows respect for the client’s interest in alternative therapies and offers guidance on how to choose a reliable and qualified provider. Alternative therapies can provide some benefits for people with rheumatoid arthritis, such as reducing pain, inflammation, and stiffness, but they should be used as a complement to conventional treatments and not as a substitute.
Choice B is wrong because it implies that the client has no role in deciding their own treatment plan and that alternative therapies are not worth considering.
This may discourage the client from sharing their preferences and concerns with the provider.
Choice C is wrong because it suggests that online support groups are a reliable source of information about alternative remedies, which may not be true.
Online sources may contain inaccurate, misleading, or harmful information that could jeopardize the client’s health and safety.
Choice D is wrong because it encourages the client to try any therapy that fits their personal belief system, without considering the evidence, effectiveness, or potential risks of such therapies. Some alternative therapies may interact with medications, cause side effects, or worsen the condition.
Normal ranges for rheumatoid arthritis are not applicable in this question, as it is not asking about laboratory values or disease activity measures. However, some common tests used to diagnose and monitor rheumatoid arthritis include erythrocyte sedimentation rate (ESR), Creactive protein (CRP), rheumatoid factor (RF), anti-cyclic citrullinated peptide (anti-CCP) antibodies, and joint ultrasound or X-ray.
The normal ranges for these tests may vary depending on the laboratory and the method used.
Correct Answer is D
Explanation
The correct answer is choice D. Administer a cathartic suppository 30 min prior to scheduled defecation times. This is because a cathartic suppository stimulates the nerve endings in the rectum, causing a contraction of the bowel and facilitating defecation. This is especially helpful for clients who have an upper motor neuron or reflexic bowel, which means they have lost the ability to feel when the rectum is full and have a tight anal sphincter muscle. A
bowel program is a way of controlling or moving the bowels after a spinal cord injury, which may affect normal bowel function depending on the spinal level involved. A bowel program aims to achieve regular bowel movements, prevent constipation or impaction, and avoid accidents.
Choice A is wrong because encouraging a maximum fluid intake of 1,500 mL per day is not enough to prevent constipation and promote bowel health. A fluid intake of at least 2,000 mL per day is recommended for most adults.
Choice B is wrong because increasing the amount of refined grains in the client’s diet can worsen constipation and reduce stool bulk.
Refined grains are low in fiber, which is essential for normal bowel function. A high-fiber diet of at least 20 to 35 grams per day is advised for clients with spinal cord injury.
Choice C is wrong because providing the client with a cold drink prior to defecation can have the opposite effect of stimulating the bowel.
Cold drinks can slow down the digestive process and reduce peristalsis, which is the movement of food through the intestines. Warm or hot drinks can help stimulate the bowel and increase peristalsis.
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