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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Acetaminophen is a suitable option for pain relief in clients with a history of peptic ulcer because it does not typically irritate the gastric mucosa or increase the risk of gastrointestinal bleeding.
B. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of gastric ulceration and bleeding, especially in clients with a history of peptic ulcer.
C. Aspirin is also an NSAID and can increase the risk of gastric ulceration and bleeding, particularly in individuals with a history of peptic ulcer.
D. Ketorolac is an NSAID with a high risk of gastrointestinal side effects, including peptic ulceration and bleeding, and should be avoided in clients with a history of peptic ulcer.
Correct Answer is ["A","B","C"]
Explanation
The presence of more frequent headaches and difficulty sleeping, coupled with a significant increase in blood pressure (BP 169/91 mm Hg), could suggest potential adverse effects of the medication phenelzine, which is known to cause headaches and hypertensive reactions. It is crucial for the nurse to monitor these symptoms closely, as they may require medical attention and could indicate the need for an adjustment in the client's treatment plan. The client's vital signs should be regularly monitored, and any new or worsening symptoms should be reported to the healthcare provider promptly to ensure the client's safety and well-being.
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