A nurse is observing a newly licensed nurse prepare a sterile field. For which of the following actions should the nurse intervene?

Positions the wrapped package on the bedside table so the outer flap is away from her.

Holds gauze packages 15 cm (6 in) above the sterile field.

Holds a bottle of solution with the label away from the palm of the hand.

Wears sterile gloves when moving sterile items on the sterile field.

Answer and Explanation

The Correct Answer is C

A. Positions the wrapped package on the bedside table so the outer flap is away from her: This action is correct because opening the flap away from the body minimizes the risk of contaminating the sterile field.

B. Holds gauze packages 15 cm (6 in) above the sterile field: This action is correct. Dropping sterile items from a height of 6 inches or more prevents contamination by ensuring they do not touch the edges or outside surfaces of the sterile field.

C. Holds a bottle of solution with the label away from the palm of the hand: When pouring a solution, the label should be held toward the palm of the hand to protect it from damage caused by spills. A damaged label could make it difficult to identify the solution, increasing the risk of error.

D. Wears sterile gloves when moving sterile items on the sterile field: This action is appropriate. Sterile gloves help maintain the sterility of the field and are required when manipulating sterile items.

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Free Nursing Study Resources

Correct Answer is ["B","C","E"]

Explanation

A. Tinnitus is not commonly associated with acute cocaine toxicity.
B. Tremor is a common finding in acute cocaine toxicity due to increased sympathetic nervous system activity.
C. Agitation is common in acute cocaine toxicity as a result of CNS stimulation.
D. Bradycardia is not typically seen; tachycardia is more common.
E. Fever can occur as a symptom of acute cocaine toxicity.

A. A client with diabetes mellitus who has a leg ulcer B. An adolescent client who has a leg fracture and has been using crutches for the past 2 days C. An older adult client who is confused and has urinary frequency D. A client who is 1 day postoperative and has a nursing assistant helping him out of bed

Correct Answer is C

Explanation

A. A client with a leg ulcer may have limited mobility but not necessarily the highest fall risk.
B. An adolescent using crutches is at some risk but typically has better balance and coordination than older adults.
C. An older adult who is confused and has urinary frequency is at the highest risk for falls due to impaired cognitive function and frequent need to get up to use the bathroom, which increases the likelihood of falls.
D. A postoperative client with assistance is less likely to fall compared to an unassisted confused older adult.

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A nurse is observing a newly licensed nurse prepare a sterile field. For which of the following actions should the nurse intervene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has acute cocaine toxicity. Which of the following findings should the nurse expect? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

A nurse on the medical-surgical unit is conducting a fall risk assessment for four clients. The nurse should identify that which of the following clients is the greatest risk for a fall?

Correct Answer is C

Explanation

A nurse is assessing a client before administering a unit of packed RBCs. The nurse should identify which of the following data as most important to obtain prior to the infusion?

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