A nurse is preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take. (Placethem in the order of performance. Use all the steps.)
Open the innermost lower flap of the sterile kit while standing away from the sterile field.
Open each side flap of the sterile kit individually while pulling to the side.
Open the outside cover of the sterile kit and remove the dust cover.
Grasp the outermost flap of the sterile kit while opening away from the body.
Prepare a dry work surface above the waist level.
The Correct Answer is E,C,D,B,A
Choice E Reason:
Preparing a dry work surface above the waist level. It's crucial to start by selecting and preparing an appropriate area for setting up the sterile field. This surface needs to be clean, dry, and above the waist level to maintain sterility and prevent contamination.
Choice C Reason:
Opening the outside cover of the sterile kit and remove the dust cover. This step involves opening the sterile kit without touching the inside contents to maintain sterility. Removing the outer cover exposes the sterile packaging and prepares for further steps.
Choice D Reason:
Grasping the outermost flap of the sterile kit while opening away from the body. By carefully opening the outermost flap, the nurse ensures that the sterile contents remain protected. Opening away from the body helps prevent accidental contamination from clothing or movements.
Choice B Reason:
Opening each side flap of the sterile kit individually while pulling to the side. Sequentially opening the side flaps maintains the sterile field and allows access to the inner contents without compromising sterility.
Choice A Reason:
Opening the innermost lower flap of the sterile kit while standing away from the sterile field. This final step involves accessing the innermost contents of the sterile kit while maintaining a safe distance to avoid accidental contamination. It ensures the contents within the sterile field remain protected until needed for the dressing change.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
"I'll listen to my favorite music to take my mind off the pain." This statement refers to distraction techniques, like listening to music, which can help manage pain but isn't specifically guided imagery.
Choice B Reason:
"I'll think about my grandfather's farm to reduce pain." This statement indicates an understanding of this technique. Guided imagery involves creating a detailed mental image or scenario that promotes relaxation and diminishes pain perception. In this case, the client visualizing a familiar, pleasant place like their grandfather's farm can be an effective form of guided imagery to alleviate pain by diverting attention and inducing relaxation.
Choice C Reason:
"I'll use focused breathing to control my pain." This statement does not indicate an understanding of this technique.
Focused breathing, while beneficial for relaxation and pain management, is a different technique from guided imagery.
Choice D Reason:
"I'll learn to notice the sensation of muscle tension." This statement refers to progressive muscle relaxation, a technique involving systematically tensing and relaxing muscle groups, which isn't guided imagery.
Correct Answer is A
Explanation
Choice A Reason:
A client can withdraw consent at any time is appropriate. This statement is accurate. Informed consent is a voluntary process, and a client has the right to withdraw their consent at any point before or during a medical procedure.
Choice B Reason:
A family member should witness the client's consent is not a standard practice. Typically, a witness is someone who is neutral and not directly involved in the procedure.
Choice C Reason:
A nurse is responsible for obtaining informed consent is not entirely accurate. While nurses may provide information and answer questions, obtaining informed consent is typically the responsibility of the healthcare provider performing the procedure.
Choice D Reason:
A minor who is pregnant is unable to give consent is not a universally true statement. The ability of a minor to give consent can vary based on legal and ethical considerations, and it may depend on local laws and regulations.
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