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.

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Correct Answer is D

Explanation

A) "Increased erythrocyte sedimentation rate.": An increase in the erythrocyte sedimentation rate (ESR) indicates inflammation or the presence of disease but does not reflect a response to epoetin alfa, which aims to increase red blood cell production.

B) "Increased neutrophil count.": Epoetin alfa primarily stimulates erythropoiesis (red blood cell production) and does not significantly affect neutrophil counts. Therefore, an increased neutrophil count is not a relevant therapeutic response.

C) "Increased platelet count.": Epoetin alfa is not directly aimed at increasing platelet counts. While it can have some indirect effects on platelets due to increased hematocrit, a higher platelet count alone does not indicate a therapeutic response to this medication.

D) "Increased hemoglobin level.": An increased hemoglobin level is the primary therapeutic target of epoetin alfa. This medication is used to treat anemia, particularly in patients with chronic kidney disease or those undergoing chemotherapy, by stimulating the production of red blood cells and thus raising hemoglobin levels.

A. Provide chilled formula. B. Administer feedings at a slower rate. C. Discard the open can of formula after 36 hr. D. Flush the tube with 10 mL of water after feedings.

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.

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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 evaluating the laboratory values of a client who is receiving epoetin alfa. Which of the following findings indicates a therapeutic response to the medication?

Correct Answer is D

Explanation

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

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