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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A Reason:

Pushing the skin down while gently removing the tape is incorrect. Pushing the skin while removing tape could cause unnecessary discomfort or trauma to the skin and the incision area. Gentle removal of tape without pulling the skin is recommended to avoid skin injury.

Choice B Reason:

Drying the incision with sterile gauze pads is incorrect. Generally, it's advisable not to dry the incision site with sterile gauze pads as this might cause trauma or disruption to the healing tissues. Patting the incision site dry or allowing it to air dry gently after cleansing is preferable.

Choice C Reason:

Lifting the soiled dressing so that the underside faces the client is correct. Lifting the soiled dressing in a manner that the underside faces the client helps prevent potential contamination of the wound by minimizing contact between the external surface of the dressing and the incision site. This technique reduces the risk of introducing pathogens into the wound during the dressing change.

Choice D Reason:

Cleaning around the drain site using horizontal strokes is incorrect. When cleaning around the drain site, it's typically recommended to use gentle and careful motions without specific emphasis on strokes, as this might cause friction or trauma to the area around the drain. Instead, using gentle circular motions or dabbing around the site is often advised for wound care.

A. Rub the puncture site with an alcohol pad. B. Apply firm pressure to the puncture site. C. Wrap the client's hand in a warm washcloth. D. Have the client raise his hand.

Correct Answer is C

Explanation

Choice A Reason:

Rubbing the puncture site with an alcohol pad is inappropriate. Rubbing the puncture site with an alcohol pad can cause vasoconstriction and make it more difficult to obtain a blood sample.

Choice B Reason:

Applying firm pressure to the puncture site is inappropriate. Applying firm pressure can further reduce blood flow to the puncture site, making it more challenging to collect an adequate blood sample.

Choice C Reason:

Wrapping the client's hand in a warm washcloth is appropriate. Applying a warm compress to the puncture site can help dilate the blood vessels and improve blood flow, making it easier to obtain a sufficient blood sample. This is especially beneficial for older adults who may have reduced blood flow to the extremities.

Choice D Reason:

Having the client raise his hand is inappropriate. Raising the hand may not be as effective as applying a warm washcloth in promoting blood flow to the puncture site. The warm washcloth helps to encourage vasodilation and improve the chances of obtaining an adequate blood sample.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is replacing a dressing for a client who has an abdominal incision with a closed wound drain. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is collecting a capillary blood sample from an older adult client. After puncturing the client's finger, the nurse is unable to obtain an adequate amount of blood. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client who has an ostomy. Which of the following statements by the client indicates an understanding of the teaching?

A home health nurse is reinforcing teaching about dietary needs with the son of a client. The son states, "I don't know what to do because he's not eating." Which of the following responses should the nurse make?

A nurse is reinforcing teaching with a group of newly licensed nurses regarding client confidentiality. In which of the following situations nurse disclose health information without the client's written consent?

A nurse is caring for a client who is scheduled for a CT scan that requires contrast dye. Which of the following actions is the priority for the nurse to take?

A nurse is coordinating care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

A nurse is caring for a client who is pulling on his NG tube. Which of the following actions should the nurse take first?

A nurse is assisting with the care of a client who has a closed chest tube drainage system. Which of the following actions should the nurse take?

A nurse is reinforcing discharge teaching about fecal occult blood testing with a client. Which of the following instructions should the nurse include in the teaching?