A charge nurse is educating a newly licensed nurse on how to perform a sterile dressing change on a client. Which of the following action indicates an understanding of the teaching?

The nurse handled the sterile gauze with clean gloves on.

The nurse opened the package of gauze toward their body.

The nurse placed a bottle of saline on the sterile field.

The nurse kept their hands above the waist during the dressing change.

Answer and Explanation

The Correct Answer is D

A. The nurse handled the sterile gauze with clean gloves on: Handling sterile gauze with clean, non-sterile gloves contaminates the gauze and compromises the sterile field. Sterile gloves or sterile instruments must be used to maintain sterility.

B. The nurse opened the package of gauze toward their body: Opening a sterile package toward the body increases the risk of contaminating the sterile field. The first flap should always be opened away from the body to maintain proper sterile technique.

C. The nurse placed a bottle of saline on the sterile field: Placing a non-sterile item, such as an unsterilized saline bottle, onto a sterile field contaminates the entire field. Only sterile items should touch the sterile field.

D. The nurse kept their hands above the waist during the dressing change: Maintaining hands above the waist is crucial in sterile technique. Anything held below waist level is considered contaminated, so this action shows proper understanding of maintaining sterility.

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Correct Answer is A

Explanation

A. Ask the client's family about cultural or religious practices regarding postmortem care: Respecting the client's and family's cultural and religious preferences is an important aspect of providing dignified and individualized postmortem care. Some practices may have specific rituals that should be honored.

B. Remove the client's dentures from their mouth before rigor mortis begins: Dentures are usually placed back into the client's mouth, not removed, to maintain a natural facial appearance and support the facial structure before rigor mortis sets in.

C. Turn on all the lights in the room before the family views the client's body: Creating a calm, peaceful environment is preferred when the family views the body. Harsh lighting may feel overwhelming or intrusive during such an emotional time.

D. Position the client's bed flat without a pillow under their head: Elevating the head of the bed slightly and placing a pillow under the head can help prevent blood from pooling in the head and face, preserving a more natural appearance. Leaving the bed flat is not ideal.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"D"}

Explanation

alcohol intoxication: Although the client consumed one beer, this small amount is unlikely to cause unresponsiveness, respiratory depression, or the need for naloxone administration. Alcohol intoxication alone does not explain the profound sedation and pinpoint pupils observed.
alcohol withdrawal: Alcohol withdrawal typically presents with signs like agitation, tremors, hallucinations, and seizures, not sedation, miosis, and depressed respiratory drive. The client’s symptoms are inconsistent with alcohol withdrawal.
hallucinogen intoxication: Hallucinogen use usually leads to agitation, paranoia, hallucinations, and dilated pupils (mydriasis), not the sedated state, respiratory depression, and miotic pupils that this client is exhibiting.
opioid intoxication: The client's unresponsiveness, respiratory depression, and pinpoint pupils, combined with a positive response to naloxone, are classic indicators of opioid intoxication. These findings directly align with the expected effects of opioid overdose.
opioid withdrawal: Opioid withdrawal presents with signs like agitation, mydriasis, diarrhea, piloerection, and flu-like symptoms. The client’s current state of sedation and miotic pupils contradicts what would be seen during opioid withdrawal.
amount of alcohol consumed: The small amount of alcohol (one beer) does not correlate with the severity of the client’s clinical presentation. Thus, alcohol consumption is not the primary factor contributing to the current state.
breath sounds: Breath sounds are clear and equal bilaterally, indicating that the lungs are not the source of the client's critical condition. There is no evidence of respiratory infection or pulmonary complications.
abdominal findings: Decreased bowel sounds are common in opioid intoxication due to decreased gastrointestinal motility. However, while supportive, this finding is less definitive than the hallmark sign of pupil constriction.
pupil characteristics: The presence of pinpoint pupils (miosis) is a hallmark sign of opioid intoxication. Miotic pupils, especially in an unresponsive client who improved after naloxone, strongly support opioid overdose as the primary diagnosis.
current temperature: The client's temperature is within normal limits, providing no significant diagnostic clue toward explaining the cause of unresponsiveness or respiratory depression.

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A charge nurse is educating a newly licensed nurse on how to perform a sterile dressing change on a client. Which of the following action indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing postmortem care to a client who just died. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is assisting with the care of a client. Select 1 condition and 1 finding to fill in each blank in the following sentence. The client likely suffered from _______ as evidenced by _______

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"D"}

Explanation

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