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 C

Explanation

A. "I have nosebleeds once per week.": Occasional nosebleeds are relatively common during pregnancy due to hormonal changes causing increased vascularity and congestion of the nasal passages. While the frequency should be noted, it's generally not a priority to report unless they are severe, frequent, or difficult to control.

B. "My heart feels like it skips a beat.": Palpitations can occur during pregnancy because of increased blood volume and changes in cardiovascular function. Occasional palpitations are typically benign but should be further evaluated if they become persistent or are associated with other symptoms like chest pain.

C. "I am experiencing persistent headaches.": Persistent headaches during pregnancy, especially after 20 weeks gestation, can be a warning sign of preeclampsia, a serious hypertensive disorder. Reporting this symptom immediately is critical to assess for elevated blood pressure, proteinuria, and other complications.

D. "The palms of my hands are red and blotchy.": Red, blotchy palms, known as palmar erythema, are a common and harmless finding during pregnancy due to increased estrogen levels. It does not usually indicate any serious condition and does not require urgent reporting.

A. Ringing in the ears B. Black, tarry stools C. Fine hand tremors D. Diarrhea

Correct Answer is B

Explanation

A. Ringing in the ears: Ringing in the ears (tinnitus) is not a common adverse effect of enoxaparin. It is typically associated with medications like aspirin or other salicylates, not low-molecular-weight heparins like enoxaparin.

B. Black, tarry stools: Black, tarry stools are a sign of gastrointestinal bleeding, which is a serious potential adverse effect of anticoagulant medications like enoxaparin. Clients taking enoxaparin should be instructed to report this symptom immediately, as it could indicate internal bleeding.

C. Fine hand tremors: Fine hand tremors are not a known adverse effect of enoxaparin. They are more commonly associated with other medications, such as certain psychiatric drugs or neurologic conditions.

D. Diarrhea: Diarrhea is not a common adverse effect of enoxaparin. While gastrointestinal symptoms can occur with many medications, it is not a primary concern or indication for discontinuing enoxaparin.

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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

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