A nurse is preparing a sterile field for the insertion of a urinary catheter. Identify the sequence of actions the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
Perform hand hygiene.
Place the sterile package on the work surface.
Open the outermost flap of the package away from the body.
Open the side flaps of the package.
Open the innermost flap of the package toward the body.
Use the inner surface of the package as a sterile field.
The Correct Answer is A,B,C,D,E,F
To prepare a sterile field for the insertion of a urinary catheter, the nurse should follow the sequence of actions in the following order:
1. Perform hand hygiene.
2. Place the sterile package on the work surface.
3. Open the outermost flap of the package away from the body.
4. Open the side flaps of the package.
5. Open the innermost flap of the package toward the body.
6. Use the inner surface of the package as a sterile field.
Following this sequence ensures that the nurse maintains proper hand hygiene, prepares the sterile package, and opens it in a way that maintains sterility. Opening the flaps in the correct order helps create a sterile field within the package, which can be used for the insertion of the urinary catheter.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
From the given statements, the nurse can identify the following statements as indicating the effectiveness of cimetidine treatment:
"I don't have as much heartburn after I eat anymore.": Cimetidine is a histamine-2 receptor antagonist commonly used to reduce stomach acid production. Decreased heartburn after eating suggests that the medication has been effective in reducing excessive acid production and relieving heartburn symptoms.
"I can sleep while lying flat again.": Cimetidine can help alleviate symptoms of gastroesophageal reflux disease (GERD) by reducing stomach acid. Improved ability to sleep while lying flat suggests that the medication has successfully reduced acid reflux and related symptoms.
The following statements do not directly indicate the effectiveness of cimetidine treatment: ● "I noticed that I have had less urge to smoke lately."
● "I occasionally have stomach pain and dark stools."
● "I have not been as dizzy as I was before."
These statements may be unrelated to the effects of cimetidine or may require further assessment to determine their significance. It's important for the nurse to address any concerns or symptoms mentioned by the client and evaluate their overall response to the medication
Correct Answer is B
Explanation
After administering lactulose to a client with cirrhosis, the nurse should monitor for the adverse effects of diarrhea. Lactulose is a laxative commonly used in the treatment of hepatic encephalopathy, which can occur in individuals with cirrhosis. One of the intended effects of lactulose is to promote bowel movements and reduce the absorption of ammonia in the gut, thus helping to manage hepatic encephalopathy.
While lactulose can cause adverse effects such as diarrhea, it is not typically associated with peripheral edema. Peripheral edema is often seen in cirrhosis due to fluid retention caused by liver dysfunction.
Dry mouth and headache are less commonly associated with lactulose use and are not typically the primary adverse effects to monitor for in this scenario.
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