A nurse is planning to perform a sterile dressing change for a client. Which of the following actions should the nurse plan to take?
Position the wrapped package on the bedside table so the outer flap opens towards her.
Place sterile supplies within the 2.54 cm (1 in) border of the sterile field.
Use sterile forceps to move the sterile items on the sterile field.
Hold gauze packages 7.6 cm (3 in) above the sterile field.
The Correct Answer is D
A. Position the wrapped package on the bedside table so the outer flap opens towards her: The outer flap should always open away from the nurse to avoid reaching over the sterile field, which can contaminate it. Opening toward oneself increases the risk of contamination.
B. Place sterile supplies within the 2.54 cm (1 in) border of the sterile field: The 1-inch border around the sterile field is considered contaminated. Placing sterile items within this area makes them unsterile and unsuitable for use in the procedure.
C. Use sterile forceps to move the sterile items on the sterile field: Once an item is placed on the sterile field, it can be moved with sterile gloves or kept in place. Using sterile forceps unnecessarily increases the risk of contamination and is not required for maintaining sterility.
D. Hold gauze packages 7.6 cm (3 in) above the sterile field: Sterile items should be dropped onto the sterile field from a height of 6–12 inches to maintain sterility while avoiding contamination. Holding the gauze package 7.6 cm above meets this standard practice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","F"]
Explanation
A. Obtain consent from the client without confirming understanding: Consent is not valid unless the client fully understands the procedure, risks, and benefits; skipping this step is unsafe and legally problematic.
B. Provide education to decrease the client's anxiety: Explaining the procedure, risks, and benefits helps the client make an informed decision and reduces fear, which is essential for valid verbal consent.
C. Coerce the client into giving consent quickly: Coercion invalidates informed consent and violates ethical and legal standards of care.
D. Verify the client understands the information provided: Ensuring comprehension confirms that the client can make an informed choice, which is a key element of informed consent.
E. Ensure the client is legally capable of consenting: The client must have the legal capacity to consent, including age and mental competency, to validate the agreement for the procedure.
F. Ignore the client's questions about the procedure: Failing to answer questions prevents the client from making an informed decision, which is a violation of patient rights and informed consent principles.
Correct Answer is C
Explanation
A. Restrict oral fluid intake during waking hours: Limiting fluids can lead to dehydration and concentrated urine, increasing the risk of urinary tract infections. Adequate hydration is essential while retraining the bladder, so fluid restriction is not recommended.
B. Encourage the client to hold her breath when feeling the urge to urinate: Holding the breath does not effectively control bladder contractions and may cause discomfort or increase abdominal pressure. Behavioral techniques like scheduled voiding are more effective.
C. Assist the client to the bathroom every 2 hr.: Scheduled toileting is a key component of bladder retraining. Assisting the client to void at regular intervals helps gradually increase bladder capacity and improve continence by reducing urgency and accidents.
D. Provide adult diapers until bladder retraining is successful: While adult diapers may be used for safety and hygiene, relying on them does not actively promote bladder control. They are a supportive measure but do not facilitate the retraining process itself.
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