A nurse is preparing to complete a sterile dressing change for a client's wound. Which of the following actions should the nurse take first?
Open the flap on the sterile kit nearest to the nurse and place the flap on the work surface.
Open the side flap of the sterile kit, allowing it to lie flat on the work surface.
Open the outermost flap of the sterile kit away from the nurse's body
Apply sterile gloves.
The Correct Answer is C
The correct answer is C. Open the outermost flap of the sterile kit away from the nurse's body.
Rationale: The nurse should open the outermost flap of the sterile kit away from their body first, as this will prevent contamination of their clothing or hands by touching any part of
the inside surface or contents of the kit. The nurse should then open each side flap by grasping only its outer edge and pulling it toward them. The nurse should then open the flap nearest to them by grasping only its outer edge and pulling it toward them. The nurse should then apply sterile gloves before touching any part of the inside surface or contents of the kit.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is D. Compare bilateral pedal pulses.
Rationale: The nurse should compare bilateral pedal pulses to assess for adequate circulation and perfusion to the lower extremities. Buck's traction is a type of skin traction that is widely used for broken femurs and hips, as well as fractures in the socket portion of the "ball-and-socket" hip joint (acetabular fractures). It uses splints, bandages, and adhesive tapes to position a limb near the fracture, then weights and pulleys are attached and pressure is applied. The nurse should not remove the weights for 20 min for the client's report of severe pain, as this would disrupt the alignment and traction of the fracture .
The nurse should not position the knot of the rope at the top of the pulley, as this would interfere with the smooth movement of the rope and reduce the effectiveness of traction. The nurse should not apply 6.8 kg (15 lb) of weight for use in traction, as this would exceed the recommended weight limit for skin traction and could cause skin damage or nerve injury. The weight should not exceed 4.5 kilograms at any point.
Correct Answer is A
Explanation
The correct answer is A.
Wipe any excess medication from the inner canthus outward. Bacitracin ophthalmic ointment is an antibiotic that treats bacterial infections of the eye.
The nurse should apply a thin layer of ointment along the lower eyelid margin and wipe any excess medication from the inner canthus (the corner of the eye near the nose) outward with a sterile gauze pad or tissue to prevent clogging of tear ducts and spreading of infection.
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