A nurse is setting up a sterile field prior to changing a client's dressing. Which of the following actions should the nurse take?

Place a sterile kit on the overbed table above waist level.

Open the outermost flap of the sterile kit toward their body.

Turn their back to the sterile field when coughing during the procedure.

Hold a package of sterile gauze 30.5 cm (12 in) above the sterile field when dropping the gauze onto the field.

Answer and Explanation

The Correct Answer is A

The correct answer is Choice A.

Choice A rationale: Placing a sterile kit on the overbed table above waist level maintains the sterility of the field. This position ensures that the kit is not contaminated by lower surfaces or inadvertent touch, which is essential for preventing infection during dressing changes.

Choice B rationale: Opening the outermost flap of the sterile kit toward their body increases the risk of contaminating the sterile field. The first flap should be opened away from the body to maintain the sterility of the field and prevent contamination.

Choice C rationale: Turning their back to the sterile field when coughing is incorrect because it increases the risk of contamination. The nurse should step away from the sterile field and cough into their elbow or use a mask to maintain sterility.

Choice D rationale: Holding a package of sterile gauze 30.5 cm (12 in) above the sterile field when dropping the gauze onto the field is too high and increases the risk of contamination. The gauze should be held closer, approximately 6 inches above the field, to ensure accuracy and sterility.

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Correct Answer is C

Explanation

Choice A rationale:

Performing oral care once each day is not sufficient to reduce the risk of ventilator-associated pneumonia (VAP). Ventilated patients are at an increased risk of developing VAP due to the presence of an endotracheal tube that bypasses the body's natural defenses. Bacteria can accumulate in the mouth and respiratory tract, leading to pneumonia. Therefore, performing oral care only once a day is inadequate for maintaining oral hygiene and preventing VAP.

Choice B rationale:

Brushing the client's teeth with a firm-bristle toothbrush can cause trauma to the oral tissues, potentially leading to bleeding and irritation. In critically ill patients with an endotracheal tube, using a firm-bristle toothbrush can exacerbate the risk of infection and VAP. It is essential to use gentle and non-traumatic methods for oral care to maintain the integrity of the oral mucosa.

Choice C rationale:

Swabbing the client's mouth with chlorhexidine solution is the correct choice. Chlorhexidine is an antiseptic solution that effectively reduces the growth of bacteria in the oral cavity. Regular use of chlorhexidine mouthwash has been shown to decrease the risk of VAP in mechanically ventilated patients. By reducing the bacterial load in the mouth, the risk of aspiration and subsequent pneumonia is lowered, making it a crucial intervention for preventing VAP.

Choice D rationale:

Raising the head of the bed by 15° for oral care is an important measure to prevent aspiration during oral care. However, it alone is not sufficient to reduce the risk of VAP. While proper head positioning helps prevent the entry of oral secretions into the lower respiratory tract, it must be combined with effective oral hygiene practices, such as using chlorhexidine solution, to comprehensively reduce the risk of VAP.

A. 0.4 mL. B. 0.8 mL. C. 1 mL. D. 1.6 mL.

Correct Answer is A

Explanation

To calculate how many milliliters (mL) of diazepam oral solution should be administered, you can use the following formula:

Dose (mL) = Desired dose (mg) / Concentration (mg/mL)

In this case, the desired dose is 2 mg, and the concentration of the diazepam oral solution is 5 mg/1 mL.

Dose (mL) = 2 mg / 5 mg/mL = 0.4 mL

So, the nurse should administer 0.4 mL of diazepam oral solution with each dose. The correct answer is:

A) 0.4 mL.

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A nurse is setting up a sterile field prior to changing a client's dressing. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following interventions should the nurse include to reduce the client's risk for ventilator-associated pneumonia?

Correct Answer is C

Explanation

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Correct Answer is A

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