A nurse assisting a provider with a sterile procedure prepares to pour a sterile solution onto a piece of gauze. In which order should the nurse perform the steps of pouring the solution? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Remove the bottle cap.
Place the bottle cap inside up on clean surface.
Pick up the bottle with the label facing his palm.
Pour 1 to 2 mL into a receptacle.
Pour the solution onto the gauze.
The Correct Answer is C,A,D,E,B
To pour the sterile solution onto a piece of gauze, the nurse should perform the steps in the following order:
1. Pick up the bottle with the label facing his palm.
2. Remove the bottle cap.
3. Pour 1 to 2 mL into a receptacle.
4. Pour the solution onto the gauze.
5. Place the bottle cap inside up on a clean surface.
It is important to maintain sterility throughout the procedure to prevent contamination. By following this order, the nurse ensures that the solution is poured onto the gauze while minimizing the risk of contamination. Placing the bottle cap inside up on a clean surface after removing it helps maintain the sterility of the cap as well.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A,B,C,D,E
Explanation
When removing personal protective equipment (PPE) after caring for a client in contact isolation, the nurse should follow the steps in the following order:
1. Remove gloves.
2. Remove protective eyewear.
3. Remove gown.
4. Remove mask.
5. Perform hand hygiene.
By following this sequence, the nurse ensures that the removal of PPE is done in a way that minimizes the risk of contamination. Removing gloves first helps prevent the spread of potential contaminants on the hands. Removing protective eyewear next avoids any potential contact with the face or eyes during the removal process. Removing the gown comes next, followed by the mask. Lastly, performing hand hygiene after removing all PPE helps ensure the hands are thoroughly cleaned.
Correct Answer is D
Explanation
When the client experiences cramping during the enema administration, it indicates that the colon is becoming distended. By allowing the client to expel some of the fluid, the pressure in the colon is reduced, which can help alleviate the discomfort and cramping. The nurse should pause the administration of the enema and allow the client to release some fluid before continuing.
The other options mentioned are not appropriate or effective actions to relieve the client's discomfort:
Lowering the height of the solution container: Lowering the height of the solution container will decrease the force of the fluid flow but may not address the underlying cause of the cramping. Allowing the client to expel some fluid is a more appropriate intervention.
Stopping the enema and documenting that the client did not tolerate the procedure: While it is important to monitor the client's tolerance during the procedure, abruptly stopping the enema and documenting intolerance may not be necessary if the discomfort can be relieved by allowing the client to expel some fluid. The nurse should prioritize relieving the discomfort before deciding to stop the procedure.
Encouraging the client to bear down: Bearing down or pushing can increase intra-abdominal pressure and exacerbate the cramping. This action is not recommended in this situation.
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