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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A.Urinary specimens collected from the bag may be contaminated and do not provide a reliable sample. A sterile specimen should be collected from the catheter port if needed.

B.In male patients secure catheter to upper thigh (with penis directed downward) or abdomen (with penis directed toward chest), allowing enough slack to prevent tension.

C.Guidelines recommend that the urinary drainage bag be kept below the level of the bladder, typically lower than the waist, to ensure proper urine flow and prevent reflux.

D.Coiling the tubing can impede proper drainage, leading to potential complications like urinary retention and infection.

A. The room numbers of the clients B. The diagnoses of the clients C. The names of the clients' nearest relatives D. The telephone numbers of the clients

Correct Answer is D

Explanation

The correct answer is D. The telephone numbers of the clients are unique identifiers that can be used to verify their identities before administering medications. The room numbers, diagnoses, and names of relatives are not reliable identifiers because they can change or be shared by other clients.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an indwelling catheter with a urinary drainage system.Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse working in a rehabilitation unit is administering medications to two clients who have the same name. Which of the following identifiers should the nurse use to verify the identities of each client?

Correct Answer is D

Explanation

A nurse is reinforcing discharge teaching with a client who has a prescription for antibiotictherapy. The client reports experiencing diarrhea when taking antibiotics. Which of the following foods should the nurse recommend to lessen the occurrence of diarrhea?

A nurse is reinforcing teaching with a client who has a new prescription for atorvastatin. For which of the following adverse effects should the nurse instruct the client to monitor and report to the provider?

A nurse is reinforcing teaching to a newly licensed nurse about bowel sounds. Which of the following characteristics should the nurse use to describe hyperactive bowel sounds?

A nurse is gathering data from a client who has severe anxiety. Which of the following findings should the nurse identify as an indication that the client is experiencing a crisis?

A nurse is suctioning the airway of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following findings should the nurse identify as an indication that the suctioning has been effective?

A nurse is supervising an assistive personnel (AP) who is caring for a client who is at risk for falls. For which of the following actions by the AP should the nurse intervene?

A nurse caring for the family of a client who recently died. Which of the following actions should the nurse take?

A nurse is caring for a client who is receiving morphine for pain. Which of the following findings indicates that the client is experiencing an adverse effect of the medication?