A nurse is preparing a sterile field for a client who requires a dressing change. Which of the following actions should the nurse plan to take?

Hold the sterile package in his dominant hand and open the top flap of the package toward his body.

Drop the sterile gauze from 25.4 cm (10 in) above the sterile field.

Place objects 1.27 cm (0.5 in) inside the border of the sterile field.

Position the bottle outside the edge of the sterile field when pouring solution into a sterile container.

Answer and Explanation

The Correct Answer is D

Rationale:
A. Hold the sterile package in his dominant hand and open the top flap of the package toward his body: The top flap should be opened away from the nurse’s body to avoid reaching over and contaminating the sterile field. Opening toward the body risks touching or dropping contaminants onto the field.

B. Drop the sterile gauze from 25.4 cm (10 in) above the sterile field: Sterile items should be dropped from a minimal height, close to the field, to prevent them from bouncing, falling off, or becoming contaminated. A 10-inch drop increases the risk of contamination.

C. Place objects 1.27 cm (0.5 in) inside the border of the sterile field: The outer 1 inch (2.5 cm) of a sterile field is considered contaminated, not just 0.5 inches. Placing objects inside only 0.5 in does not guarantee sterility and may result in contamination.

D. Position the bottle outside the edge of the sterile field when pouring solution into a sterile container: Keeping the bottle outside the sterile field prevents contamination from the outside of the bottle. Only the sterile contents should enter the sterile container, maintaining the integrity of the sterile field during the dressing change.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:
A. Medication reconciliation involves reviewing all medications the client was taking at home and comparing them with the prescriptions ordered on admission. This process helps identify discrepancies, prevent omissions, duplications, or potential interactions, and ensures continuity of care.

B. Comparing a standard list of medications for a condition is not part of medication reconciliation because it may not reflect the individual client’s needs, allergies, or previous therapy. The focus should be on the client’s actual home medications.

C. This step refers to the “three checks” of medication administration, which is different from the initial reconciliation process. Reconciliation focuses on matching home medications with admission orders, not verifying labels prior to each dose.

D. While checking for allergies is a critical safety step, it is only one component of safe medication administration. Medication reconciliation is broader, ensuring that all home medications are considered and that any changes or omissions are intentional and documented.

A. Advise the client to wait 1 hr before showering or swimming. B. Instruct the client to have his testosterone checked in 1 week. C. Wear clean gloves to apply the gel. D. Apply the gel to the client's genital region.

Correct Answer is A

Explanation

Rationale:
A. Advise the client to wait 1 hr before showering or swimming: Testosterone gel should be allowed to fully absorb into the skin before washing or swimming, typically waiting at least 1 hour. This ensures optimal absorption and therapeutic effect.

B. Instruct the client to have his testosterone checked in 1 week: Testosterone levels are generally evaluated after several weeks of therapy to assess effectiveness, not after just one week.

C. Wear clean gloves to apply the gel: The client should apply the medication themselves using clean, dry hands. The nurse should wear gloves only if assisting to prevent unintentional hormone absorption.

D. Apply the gel to the client's genital region: Testosterone gel should not be applied to the genitals due to increased absorption risk and skin irritation. Recommended sites include shoulders, upper arms, or abdomen.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is preparing a sterile field for a client who requires a dressing change. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a medical-surgical unit is performing medication reconciliation for a newly admitted client. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is preparing to administer testosterone gel to a client who has hypogonadism. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is reviewing laboratory results for a client who is taking warfarin. Which of the following laboratory tests determines if the dose of medication is within the recommended target range?

A nurse is caring for an infant who has gastroenteritis. Which of the following assessment findings should the nurse report to the provider?

A nurse is caring for a toddler in the outpatient setting. Exhibits Complete the following sentence by using the lists of options. The nurse recognizes the toddler has likely developed dropdown due to dropdown.

A nurse is providing teaching to a client who has a new prescription for warfarin. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a newly admitted client who has bacterial meningitis. Which of the following actions should the nurse take?

A nurse is providing teaching to a client who has a new prescription for nifedipine. Which of the following statements should the nurse include?

A nurse is teaching a client about dietary recommendations while breastfeeding. Which of the following client statements should the nurse identify as an indication of understanding the teaching?

A nurse is reviewing the laboratory results for a female client who is receiving furosemide and digoxin. Which of the following findings should the nurse recognize increases the client's risk for developing digoxin toxicity?