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. Crackles in the lung bases: Left-sided heart failure leads to fluid buildup in the lungs due to the heart's inability to pump blood effectively. This fluid accumulation causes pulmonary congestion, which results in crackles, particularly in the lung bases. This is a common and expected finding in left-sided heart failure.

B. Anorexia: Anorexia may occur in heart failure, but it is not a primary or typical finding of left-sided heart failure. It is more commonly associated with right-sided heart failure, where digestive system congestion is more prevalent.

C. Bradycardia: Left-sided heart failure typically causes tachycardia (elevated heart rate) as the body compensates for the decreased cardiac output. Bradycardia is less commonly seen unless the client has an underlying arrhythmia or is on medications like beta-blockers.

D. Polyuria during the day: Polyuria, or excessive urination, is typically observed at night (nocturia) in clients with heart failure due to fluid redistribution when lying down. It is not commonly observed during the day.

A. Temperature 35.3°C (95.5° F) B. Heart rate 60/min C. Respiratory rate 16/min D. Blood pressure 90/60 mm Hg E. Skin cool and moist to touch. F. Pedal pulse +1 bilateral. G. Bowel sounds hypoactive in all four quadrants. H. Moderate amount of sanguineous drainage noted on the lower dressing I. Lungs clear bilateral J. Respirations even, nonlabored.

Correct Answer is ["A","B","D","E","F","G","H"]

Explanation

Temperature 35.3°C (95.5°F): Hypothermia following surgery is concerning because it may reflect poor perfusion, internal bleeding, or shock. Immediate warming measures and evaluation are necessary to prevent further deterioration.
Blood pressure 90/60 mm Hg: The client’s blood pressure is lower than previous values and indicates potential hypovolemia or ongoing blood loss. Hypotension post-surgery must be urgently addressed to avoid progression to shock.
Skin cool and moist to touch: Cool, moist skin is an early clinical sign of decreased tissue perfusion and shock. When found alongside hypotension and hypothermia, it suggests that circulatory compromise may already be developing.
Moderate amount of sanguineous drainage noted on lower dressing: Moderate bleeding post-laparoscopic surgery is abnormal. This finding, in combination with hypotension and other signs of poor perfusion, strongly suggests possible internal bleeding requiring urgent provider notification.
Hypoactive bowel sounds: Hypoactive bowel sounds are expected after abdominal surgery due to anesthesia and reduced gut motility. They are not an immediate sign of a critical complication unless accompanied by abdominal distension or severe pain, they should however be monitored.
Heart rate 60/min: A heart rate of 60/min is at the lower limit of normal. Although 60/min is still technically within normal range, the trend of decreasing heart rate from baseline 90 beats/min, especially in the setting of hypotension and signs of poor perfusion, is concerning. This decline may indicate worsening hemodynamic status and must be monitored closely for further deterioration..
Pedal pulse +1 bilateral: Diminished pedal pulses (+1) indicate reduced peripheral circulation. In isolation, it may not be critical, but when combined with hypotension and cool skin, it becomes part of the overall picture suggesting decreased perfusion and should be monitored carefully.

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Area assessed	Findings
Neurological	Drowsy but easy to arouse
Vital Signs	Temperature 35.3°C (95.5° F) Heart rate 60/min Respiratory rate 16/min Blood pressure 90/60 mm Hg Oxygen saturation 94% (oxygen at 2 L/min via nasal cannula) Rates pain as 1 on 0/10 pain scale.
Integumentary	Skin cool and moist to touch.
Cardiopulmonary	Heart rate regular. Pedal pulse +1 bilateral. Lungs clear bilateral. Respirations even, nonlabored.
Abdomen	Abdomen soft, nondistended. Bowel sounds hypoactive in all four quadrants. 2x2 gauze with a clear transparent dressing intact to right lower and upper abdominal quadrant. Moderate amount of sanguineous drainage noted on the lower dressing

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 collecting data from a client who has left-sided heart failure. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

Correct Answer is ["A","B","D","E","F","G","H"]

Explanation

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