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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Provide chilled formula: Chilled formula can be less palatable and may cause gastrointestinal discomfort, potentially worsening diarrhea. Room temperature or slightly warmed formula is generally recommended for enteral feedings to enhance tolerance and digestion.

B. Administer feedings at a slower rate: Slowing the rate of enteral feedings can help reduce gastrointestinal irritation and improve absorption, which may be particularly beneficial for a client experiencing diarrhea. This approach allows the intestines more time to process the nutrients, potentially alleviating symptoms.

C. Discard the open can of formula after 36 hr: While proper storage is important, many enteral formulas can be stored for up to 48 hours once opened. The key is to ensure the formula is stored correctly to prevent bacterial growth, but the 36-hour guideline may not be strictly necessary in all cases.

D. Flush the tube with 10 mL of water after feedings: Flushing the tube is a good practice to maintain tube patency, but the volume may not be adequate depending on the tube size and the specific protocol. Adequate flushing is essential, but it does not directly address the issue of diarrhea, which is the priority concern in this scenario.

A. "Limit your child's potassium intake while she is taking this medication." B. “Repeat the dose if your child vomits within 1 hour after taking the medication." C. "Have your child drink a small glass of water after swallowing the medication." D. "You can add the medication to a half-cup of your child's favorite juice."

Correct Answer is C

Explanation

A. "Limit your child's potassium intake while she is taking this medication.": This statement is incorrect. In fact, potassium intake should generally be adequate because digoxin can lead to increased potassium loss, and low potassium levels can increase the risk of digoxin toxicity.

B. “Repeat the dose if your child vomits within 1 hour after taking the medication.": This statement is not recommended. The nurse should advise parents to contact their healthcare provider for guidance on whether to administer a repeat dose after vomiting, as it depends on the individual situation and timing.

C. "Have your child drink a small glass of water after swallowing the medication.": This statement is appropriate as it can help ensure that the medication is swallowed properly and aids in its absorption. Adequate hydration is important for all medications.

D. "You can add the medication to a half-cup of your child's favorite juice.": This is not advisable because mixing digoxin with juice can alter the absorption of the medication. It's generally better to administer it alone to ensure proper dosing and effectiveness.

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 caring for a client who has diarrhea and is receiving intermittent enteral feedings. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is caring for a client who speaks a different language than the nurse and is using an interpreter. Which of the following actions should the nurse take when working with the interpreter?

A nurse is providing discharge teaching to a new parent about breastfeeding her infant. Which of the following statements should the nurse make?

A nurse manager on an interprofessional team is creating a disaster plan. The nurse should include in the plan that which of the following actions is the responsibility of the unit nurse during a disaster?

A nurse is discussing weight loss with a client who is concerned about losing 6.8 kg (15 lb) from an original weight of 90.7 kg (200 lb). The nurse should identify the weight loss as which of the following total percentages?

A nurse is assessing a client who is in skeletal traction for a fractured left tibia. The nurse should identify that which of the following findings indicates altered tissue perfusion of the affected extremity?

A nurse is teaching the parents of a child who has a new onset of seizures and is to undergo an electroencephalogram (EEG) about the procedure. Which of the following instructions should the nurse include in teaching?

A nurse is caring for a client who is in labor and notes that the umbilical cord is prolapsed. Which of the following actions should the nurse take?