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 A

Explanation

A. Reduced fat in the stools is correct. Pancrelipase is an enzyme replacement therapy that helps improve digestion and absorption of fats and proteins in individuals with cystic fibrosis. This treatment is especially important for those with pancreatic insufficiency, as it helps prevent the steatorrhea (fatty stools) commonly seen in these patients.

B. Decreased sodium excretion is incorrect. Pancrelipase does not directly affect sodium balance in the body. Cystic fibrosis patients may experience increased sodium excretion, which requires special management of fluid and electrolytes.

C. Improved respiratory function is incorrect. While pancrelipase improves digestion, it does not directly affect respiratory function, which is primarily impacted by the progressive lung disease in cystic fibrosis.

D. Improved absorption of vitamins B and C is incorrect. While pancrelipase helps with fat absorption, it primarily improves the absorption of fat-soluble vitamins (A, D, E, K) rather than water-soluble vitamins like B and C.

A. Inject 15 units of air into the regular insulin vial. B. Place the cap over the needle. C. Verify the dosage with another nurse. D. Withdraw 10 units of NPH insulin.

Correct Answer is A

Explanation

A. Injecting 15 units of air into the regular insulin vial is correct. When drawing up two types of insulin, the nurse should first inject air into the NPH (cloudy) insulin vial without withdrawing the medication. Then, the nurse should inject air into the regular (clear) insulin vial before withdrawing the regular insulin. This prevents contamination and maintains proper insulin mixing procedures.

B. Placing the cap over the needle is incorrect. Once insulin preparation has started, recapping the needle is unnecessary and increases the risk of contamination or needlestick injury.

C. Verifying the dosage with another nurse is incorrect at this stage. Dosage verification should be done after the correct amounts of insulin are drawn into the syringe, not before.

D. Withdrawing 10 units of NPH insulin is incorrect. The nurse should first withdraw the regular (clear) insulin before drawing up the NPH (cloudy) insulin to avoid contaminating the regular insulin with the longer-acting insulin.

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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 administering pancrelipase to a child who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment?

Correct Answer is A

Explanation

A nurse is caring for a client who has a prescription for NPH insulin 10 units and regular insulin 15 units subcutaneously. After injecting 10 units of air into the NPH insulin vial, which of the following actions should the nurse take next?

Correct Answer is A

Explanation

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