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 C

Explanation

A. Reevaluating for an ET cuff leak is important but not the immediate priority when the cause of the alarm is unknown, and the client is in distress. It is more important to ensure the client is receiving adequate ventilation.

B. Assessing for disconnected tubing is essential, but if the cause of the high-pressure alarm is unclear and the client is in distress, manual ventilation should take precedence.

C. When a high-pressure alarm sounds on a mechanical ventilator and the cause is not immediately identifiable, the nurse should prioritize the client's safety by delivering breaths manually with a resuscitation bag. This ensures that the client continues to receive oxygen while troubleshooting the ventilator issue. Manual ventilation is crucial in preventing hypoxia during periods of mechanical failure or when the cause of the alarm cannot be quickly identified.

D. Decreasing the ventilator flow rate may not address the underlying issue causing the high-pressure alarm and could potentially worsen the situation. Immediate manual ventilation is the safest action.

A. Increased bicarbonate B. Increased calcium C. Increased hemoglobin D. Increased creatinine

Correct Answer is D

Explanation

A. Chronic kidney disease often results in metabolic acidosis, leading to decreased bicarbonate levels rather than increased.
B. Chronic kidney disease commonly leads to hyperphosphatemia and hypocalcemia due to impaired renal excretion of phosphate and decreased activation of vitamin D, resulting in decreased calcium levels.
C. Chronic kidney disease often results in anemia due to decreased production of erythropoietin, leading to decreased hemoglobin levels rather than increased.
D. Increased creatinine levels are indicative of impaired renal function, a hallmark of chronic kidney disease.

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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 caring for a client receiving mechanical ventilation via an endotracheal (ET) tube. The high-pressure alarm is beeping, and the client is experiencing respiratory distress. The nurse is unable to determine the cause of the alarm. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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