A nurse is preparing a sterile field to perform a dressing change of a client's leg wound. Which of the following actions should the nurse take?

Hold the irrigation solution bottle 5 cm (2 in) above the sterile container.

Open the outer wrapper of the sterile package toward her body.

Place the irrigation solution bottle cap on the sterile field.

Place sterile objects at least 2.5 cm (1 in) from the edge of the sterile field.

Answer and Explanation

The Correct Answer is D

A. Holding the irrigation solution bottle 5 cm (2 in) above the sterile container is incorrect because the solution should be poured into a sterile container without contaminating the sterile field. The nurse should pour the solution from a height that avoids splashing and contamination.

B. Opening the outer wrapper of the sterile package toward her body is incorrect. The outer wrapper of a sterile package should be opened away from the body to avoid contamination of the sterile field.

C. Placing the irrigation solution bottle cap on the sterile field is incorrect. The cap should not be placed on the sterile field, as it may introduce contaminants.

D. Placing sterile objects at least 2.5 cm (1 in) from the edge of the sterile field is correct. This practice maintains the sterility of the field by preventing contamination from external sources.

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Correct Answer is B

Explanation

A. Store the dentures in a dry denture cup on the bedside table after cleaning.: Dentures should not be stored in a dry cup as this can lead to drying out and warping of the dentures. They should be stored in water or a denture solution to keep them moist.

B. Place a towel in the sink when cleaning the dentures.: This is correct. Placing a towel in the sink is a safety precaution to prevent dentures from breaking if they are accidentally dropped while being cleaned. It also helps prevent damage from impact with hard surfaces.

C. Remove the lower dentures before the upper dentures.: There is no specific order required for removing dentures, as both upper and lower dentures should be removed carefully and cleaned.

D. Use a circular motion to cleanse the biting surface of the dentures.: A circular motion is not the best technique for cleaning dentures. Instead, the dentures should be brushed gently with a soft toothbrush, focusing on cleaning all surfaces, including the biting surfaces, using a back-and-forth motion.

A. Measure the duration of the seizure. B. Lower the side rails of the bed when the seizure begins. C. Insert an oral airway into the client's mouth. D. Restrain the client's arms and legs to prevent injury.

Correct Answer is A

Explanation

A. Measure the duration of the seizure. This is the correct action. Monitoring the duration of the seizure is important for assessing its severity and deciding when to intervene medically. A seizure lasting longer than 5 minutes requires immediate intervention.

B. Lower the side rails of the bed when the seizure begins. This is not recommended. The side rails should be raised to protect the client from injury. Lowering them could increase the risk of falling out of bed.

C. Insert an oral airway into the client's mouth. This is incorrect. Inserting an airway into the mouth during a seizure can be dangerous and may result in injury to the client or the nurse. The client’s airway should be kept clear, but inserting an object into the mouth is not recommended.

D. Restrain the client's arms and legs to prevent injury. This is incorrect. Restraining the client during a seizure can cause injury to both the client and the nurse. It is better to allow the seizure to proceed naturally while ensuring the client is protected from injury (e.g., by placing a soft pillow under their head or cushioning hard surfaces around them).

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A nurse is preparing a sterile field to perform a dressing change of a client's leg wound. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is unable to perform ADLs and wears dentures. Which of the following actions should the nurse take when providing denture care?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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