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?

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

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

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 A

Rationale:

A. Drop the sterile gauze from 25.4 cm (10 in) above the sterile field: Dropping sterile items from a height of about 6 to 12 inches prevents contamination by keeping hands outside the sterile field and ensuring the item lands safely without touching nonsterile surfaces.

B. 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 maintain sterility and prevent the arm from crossing over the sterile field, which would risk contamination.

C. Place objects 1.27 cm (0.5 in) inside the border of the sterile field: The outer 2.5 cm (1 inch) of the sterile field is considered contaminated. Placing items only 0.5 inches inside this border would place them within the contaminated zone, risking sterile field compromise.

D. Position the bottle outside the edge of the sterile field when pouring solution into a sterile container: While the bottle should not touch the sterile field, it must be close enough to pour without splashing, and the sterile container must be inside the sterile field.

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Correct Answer is B

Explanation

Rationale:

A. Prepare an IV bolus of dextrose 5% in water: Dextrose in water does not reverse magnesium toxicity. It may be used as a fluid carrier but does not serve as an antidote or address the neuromuscular and cardiac effects of excessive magnesium.

B. Administer calcium gluconate IV: Calcium gluconate is the antidote for magnesium sulfate toxicity. It helps reverse respiratory depression, muscle weakness, and cardiac conduction delays caused by high magnesium levels, making it the immediate intervention.

C. Position the client supine: The supine position can worsen hypotension by decreasing venous return, especially in pregnant clients. Left lateral positioning is generally preferred to improve circulation to vital organs and the fetus.

D. Administer methylergonovine IM: Methylergonovine is used to treat postpartum hemorrhage, but it is contraindicated in clients with hypertension or preeclampsia due to its vasoconstrictive effects. It does not treat magnesium toxicity and could increase blood pressure dangerously.

A. A client who moved to an apartment located on higher ground than her previous home. B. A client who has frequent nightmares about the hurricane. C. A client who expresses a realization that life will not return to the way it was before the hurricane. D. A client who describes having persistent feelings of anger about the hurricane. E. A client who describes feeling disconnected from those around him following the hurricane.

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

Explanation

Rationale:

A. A client who moved to an apartment located on higher ground than her previous home: Relocating for safety is a rational coping mechanism and does not, on its own, indicate PTSD. This action reflects adaptation rather than signs of trauma-related distress.

B. A client who has frequent nightmares about the hurricane: Recurrent nightmares related to the traumatic event are a hallmark symptom of PTSD and suggest that the client is experiencing persistent re-experiencing of the trauma.

C. A client who expresses a realization that life will not return to the way it was before the hurricane: This statement reflects acceptance and realistic processing of the event, not necessarily indicative of emotional distress or dysfunction associated with PTSD.

D. A client who describes having persistent feelings of anger about the hurricane: Chronic irritability or anger following trauma is a recognized symptom of PTSD and may indicate the client is struggling with emotional regulation due to unresolved trauma.

E. A client who describes feeling disconnected from those around him following the hurricane: Emotional numbing or detachment from others is a common symptom of PTSD, often associated with difficulty in re-establishing interpersonal connections after trauma.

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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

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Correct Answer is B

Explanation

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