A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field?

Place the sterile dressing within 1.25 cm (0.5 in) of the edge of the sterile field.

Open the outermost flap of the sterile kit toward the body.

Place the cap from the solution sterile side up on a clean surface.

Set up the sterile field 5 cm (2 in) below waist level.

Answer and Explanation

The Correct Answer is C

A. Place the sterile dressing within 1.25 cm (0.5 in) of the edge of the sterile field: This action is not appropriate, as sterile items should be placed at least 2.5 cm (1 in) away from the edge of the sterile field to maintain sterility and prevent contamination.

B. Open the outermost flap of the sterile kit toward the body: The correct practice is to open the outermost flap away from the body. This technique helps prevent any contaminants from the nurse's clothing or body from falling into the sterile field.

C. Place the cap from the solution sterile side up on a clean surface: This is the correct action. By placing the cap sterile side up, the nurse minimizes the risk of contamination to the sterile solution and maintains the integrity of the sterile field.

D. Set up the sterile field 5 cm (2 in) below waist level: Setting up a sterile field below waist level increases the risk of contamination, as it may come into contact with non-sterile surfaces. The sterile field should be set up at waist level or higher to maintain sterility.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Platelet count: While a platelet count is important for assessing the risk of bleeding, it is not the primary laboratory test used to monitor the effectiveness of warfarin therapy.

B. Fibrinogen level: This test is more relevant in assessing clotting factors and conditions related to bleeding or clotting disorders, but it is not specific for monitoring warfarin.

C. aPTT: Activated partial thromboplastin time (aPTT) is primarily used to monitor unfractionated heparin therapy, not warfarin.

D. INR: The International Normalized Ratio (INR) is the key laboratory test used to monitor warfarin therapy. It indicates the blood's clotting tendency, and the provider will use this value to determine the appropriate dosage of warfarin. Therefore, it is crucial to report the INR to obtain the prescription for warfarin.

A. Determine if the client has thoughts about self-harm. B. Review the client's available social support system. C. Empower the client to feel that he is in charge of his life. D. Find the client a temporary shelter where he can feel safe.

Correct Answer is A

Explanation

A) Determine if the client has thoughts about self-harm: In situations of acute grief and trauma, assessing for suicidal ideation is the priority. The nurse must ensure the client's safety first, as the loss of a partner in such a tragic circumstance can lead to overwhelming feelings of despair and hopelessness.

B) Review the client's available social support system: While understanding the client’s social support is important for ongoing care and coping strategies, it is not the immediate priority. Ensuring the client’s safety takes precedence over evaluating their support network.

C) Empower the client to feel that he is in charge of his life: Empowering the client is a valuable goal for long-term recovery, but it should come after assessing immediate safety and mental health needs. The client may not be in a state to feel empowered until basic concerns about their well-being are addressed.

D) Find the client a temporary shelter where he can feel safe: While finding shelter is crucial for the client’s physical safety and security, this action should follow the immediate assessment of the client’s mental health and any risk of self-harm. Ensuring psychological safety is the first step before addressing logistical needs.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reporting a client's laboratory tests to the provider to obtain a prescription for the client's daily warfarin. Which of the following laboratory tests should the nurse plan to report to obtain the prescription for the warfarin?

Correct Answer is D

Explanation

A nurse is caring for a client whose partner died in a fire that destroyed their home. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is planning care for a client who is scheduled to receive a peripherally inserted central catheter in the arm. Which of the following interventions is appropriate for the nurse to include in the plan of care?

A nurse is caring for a client who is in a coma and is scheduled for a surgical procedure. Which of the following actions should the nurse take?

A nurse is caring for a client who has heart failure. Which of the following manifestations should the nurse expect?

A nurse is reviewing laboratory data from a client who has chronic kidney disease. Which of the following findings should the nurse expect?

A nurse is caring for a client who has experienced a stillbirth. Which of the following actions should the nurse take during the initial grieving process?

A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications?

A nurse is completing an admission assessment for a client who has narcissistic personality disorder. Which of the following findings should the nurse expect?

A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan?