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?

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

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.

Answer and Explanation

The Correct Answer is D

A: The sterile field should be set up at or above waist level to prevent contamination from higher surfaces, not below.
B: The outer edge (about 2.5 cm or 1 inch) of the sterile field is considered non-sterile, so placing the sterile dressing close to the edge risks contamination.

C: The outermost flap of the sterile kit should be opened away from the body to avoid reaching over the sterile field, which could lead to contamination.
D: The cap should be placed sterile side up to maintain its sterility if it needs to be reapplied to the solution bottle.

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Correct Answer is A

Explanation

A: A client who is scheduled for a colonoscopy and is taking sodium phosphate requires follow-up care because sodium phosphate can cause colonic mucosal damage and electrolyte imbalances that may affect the safety and accuracy of the colonoscopy. Sodium phosphate is a bowel preparation agent that empties the colon before the procedure, but it can also cause dehydration, kidney injury, and cardiac arrhythmias.
B: Induration following a Mantoux test indicates a reaction that may suggest tuberculosis exposure, but this is an expected result that requires assessment rather than immediate follow-up.
C: Bumetanide is a diuretic, and an increase in urination is an expected effect of this medication.
D: Warfarin is considered safe during lactation since it is not excreted in breastmilk to any measurable degree.

A. Encourage a regular sleep-wake schedule. B. Encourage naps during the day when client is tired. C. Encourage client to sleep until later in the morning D. Advise client to rise slowly from sitting position. E. Advise client to notify provider if pregnant. F. Encourage high-calorie finger foods. G. Instruct client to avoid foods that have been fermented or aged.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"B"}}

Explanation

A. Establishing a regular sleep-wake schedule can help regulate circadian rhythms and improve sleep quality, which is beneficial for managing insomnia. B. Napping during the day can disrupt the client's ability to sleep at night, exacerbating insomnia. It's generally recommended to avoid daytime naps for individuals experiencing difficulty sleeping. C. Sleeping in later in the morning can disrupt the client's sleep-wake cycle and contribute to difficulty falling asleep at night. Consistency in sleep-wake times is important for managing insomnia. D. Rising slowly from a sitting position can help prevent orthostatic hypotension, especially for clients taking trazodone, which can cause dizziness or lightheadedness upon standing. E. Trazodone is a medication that may have risks associated with use during pregnancy, so it's important for the client to inform their provider if they are pregnant or planning to become pregnant. F. Loss of appetite is a concern, but encouraging high-calorie finger foods may not address the underlying issue. It's important to address the root cause of the appetite loss and provide appropriate interventions, which may include dietary counseling and addressing stress. G. There is no indication in the scenario that fermented or aged foods would negatively affect the client's condition or interact with trazodone. It's important to focus on addressing the primary concerns of stress, difficulty sleeping, and loss of appetite.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings requires follow-up care?

Correct Answer is A

Explanation

A nurse is caring for a client in the outpatient health clinic Exhibits For each potential nursing intervention, click to specify if the intervention is indicated or not indicated.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"B"}}

Explanation

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