50. A nurse is preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps)

Open the outside cover of the sterile kit and remove the dust cover

Grasp the outermost flap of the sterile kit while opening away from the body.

Prepare a dry work surface above the waist level

Open the innermost lower flap of the sterile kit while standing away from the sterile field

Open each side flap of the sterile kit individually while pulling to the side

Answer and Explanation

The Correct Answer is C,A,B,D,E

A.   Opening the outside cover of the sterile kit and removing the dust cover exposes the sterile supplies within the kit.
B.   Grasping the outermost flap of the sterile kit while opening away from the body helps maintain the sterility of the contents within the kit.

C.   Preparing a dry work surface above the waist level ensures that the sterile field is established at a proper height and that the nurse's hands are at the appropriate level for working within the sterile field.
D.   Opening the innermost lower flap of the sterile kit while standing away from the sterile field allows the nurse to access the sterile supplies without contaminating the sterile field.
E.   Opening each side flap of the sterile kit individually while pulling to the side further establishes the sterile field and provides access to the sterile supplies.

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Correct Answer is B

Explanation

A. Cleaning around the stoma with a moisturizing soap is not recommended. Moisturizing soaps can leave a residue that may interfere with the adhesion of the skin barrier. The client should use warm water or a mild, non-moisturizing soap to clean the area.

B. Pressing on the skin barrier for 30 seconds to ensure that it adheres is correct. This technique helps secure the barrier to the skin, creating a good seal and reducing the risk of leaks.

C. Cutting an opening in the skin barrier that is 1/2 inch larger than the stoma is incorrect. The opening should be about 1/8 inch larger than the stoma to ensure a snug fit, which helps protect the surrounding skin from exposure to effluent.

D. Applying a thin layer of talc powder around the stoma before placing the appliance is not appropriate. Powders are typically used to manage irritated skin but should be avoided unless specifically recommended by a healthcare provider. Overuse can interfere with the appliance’s adhesion.

A. To an insurance agency in regard to a life insurance policy B. To a family member when the client is not available C. To a medical interpreter service on behalf of a client D. To an employer for a pre-employment screening

Correct Answer is C

Explanation

Rationale:

A. Disclosing health information to an insurance agency without written consent is a violation of client confidentiality.

B. Disclosing health information to a family member without written consent is a violation of client confidentiality.

C. Disclosing health information to a medical interpreter service on behalf of a client is permissible under HIPAA regulations, as long as the interpreter is bound by confidentiality requirements.

D. Disclosing health information to an employer without written consent is a violation of client confidentiality.

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50. A nurse is preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has an ostomy. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a group of newly licensed nurses regarding client confidentiality. In which of the following situations can the nurse disclose health information without the client's written consent?

Correct Answer is C

Explanation

A nurse at a long-term care facility is caring for an older adult client who has dementia and is at risk for malnutrition. Which of the following actions should the nurse take to promote an increase in food intake?

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