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 C

Explanation

A) Abdomen: Assessing skin turgor on the abdomen in older adults is not recommended due to the natural loss of elasticity in this area, which can lead to inaccurate results.

B) Neck: The neck is also not an ideal location for assessing skin turgor in older adults, as the skin in this area can be affected by age-related changes, leading to unreliable assessments.

C) Sternum: The sternum is a preferred site for assessing skin turgor in older adults. The skin in this area tends to retain its elasticity better than other areas, providing a more accurate assessment of hydration status.

D) Shoulder: The shoulder is not commonly used for assessing skin turgor in older adults, as it may not provide reliable results due to age-related changes in skin elasticity. The sternum remains the best option for this assessment.

A. A client who has a hip fracture and a new onset of tachypnea. B. A client who has sinus arrhythmia and is receiving cardiac monitoring. C. A client who has diabetes mellitus and an HbA1c of 7.2% (less than 7%). D. A client who has epidural analgesia and weakness in the lower extremities.

Correct Answer is A

Explanation

A) A client with a hip fracture and new onset of tachypnea is a priority for assessment. Tachypnea can indicate respiratory distress, possible pulmonary embolism, or complications related to the fracture. Prompt evaluation is critical to ensure timely intervention and prevent further complications.

B) A client with sinus arrhythmia receiving cardiac monitoring is generally stable, as sinus arrhythmia is often benign and not immediately life-threatening. While ongoing monitoring is important, this client does not require immediate assessment over those presenting with more acute symptoms.

C) A client with diabetes mellitus and an HbA1c of 7.2% is slightly above the recommended target, but this finding does not indicate an immediate concern requiring urgent assessment. This client can be monitored but does not need priority attention compared to others with acute issues.

D) A client with epidural analgesia and weakness in the lower extremities is concerning, but if the client is stable and there are no additional alarming signs (such as respiratory distress or severe neurological changes), they can be assessed after more critical clients. Monitoring for side effects from epidural analgesia is important, but it is not as urgent as assessing new respiratory symptoms.

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 assessing the skin turgor of an older adult client. In which of the following areas should the nurse lift the skin?

Correct Answer is C

Explanation

A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?

Correct Answer is A

Explanation

A nurse is providing teaching to family members of a client who has dementia. Which of the following instructions should the nurse include in the teaching?

A nurse in the emergency department is assessing a newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following actions should the nurse take first?

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 admitting a client who is hesitant to create advance directives due to concerns about affording legal representation. Which of the following statements should the nurse make?

A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?

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 providing discharge teaching to a client who has cancer and a prescription for a fentanyl 25 mcg/hr transdermal patch. Which of the following instructions should the nurse include in the teaching?