A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?
Place sterile gauze over areas of spilled solution within the sterile field.
Hold the irrigation solution bottle with the label facing away from the palm of the hand.
Remove the cap and place it sterile-side up on a clean surface.
Hold the bottle in the center of the sterile field when pouring the solution.
The Correct Answer is C
The correct answer is choice C. Remove the cap and place it sterile-side up on a clean surface.
Choice A rationale:
Placing sterile gauze over areas of spilled solution within the sterile field is not recommended. Spilled solution can compromise the sterility of the field, and covering it with gauze does not restore sterility. Instead, the nurse should avoid spilling solution to maintain the sterile field.
Choice B rationale:
Holding the irrigation solution bottle with the label facing away from the palm of the hand is incorrect. The correct technique is to hold the bottle with the label facing the palm. This prevents the label from getting wet and unreadable, ensuring that the nurse can always identify the solution correctly.
Choice C rationale:
Removing the cap and placing it sterile-side up on a clean surface is the correct action. This maintains the sterility of the cap, preventing contamination when it is replaced on the bottle. Ensuring the cap remains sterile is crucial for maintaining the sterility of the solution.
Choice D rationale:
Holding the bottle in the center of the sterile field when pouring the solution is incorrect. The bottle should be held outside the sterile field to prevent contamination. The solution should be poured carefully to avoid splashing and compromising the sterile field.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. Increase exercise.
Exercise can help stimulate bowel movements and prevent constipation, which is a common side effect of opioid medications.
Exercise can also improve blood circulation, reduce stress, and enhance mood, which can benefit clients who have chronic pain.
Choice A is wrong because decreasing insoluble fiber intake can worsen constipation.
Insoluble fiber adds bulk to the stool and helps it pass more easily through the colon.
Clients who take opioid medications should increase their intake of insoluble fiber from sources such as whole grains, fruits, vegetables, nuts, and seeds.
Choice C is wrong because drinking less water can lead to dehydration and hardening of the stool, which can make it more difficult to pass.
Clients who take opioid medications should drink plenty of water to keep the stool soft and moist.
Choice D is wrong because taking a laxative every day can cause dependence, tolerance, and electrolyte imbalance.
Laxatives should be used only as a last resort and under the guidance of a health care provider.
Clients who take opioid medications should try other methods of preventing constipation first, such as increasing exercise, fiber, and water intake.
Correct Answer is A
Explanation
The correct answer is choice A: “We can review some information to help you select a safe alternative practitioner.” This statement shows respect for the client’s interest in alternative therapies and offers guidance on how to choose a reliable and qualified provider. Alternative therapies can provide some benefits for people with rheumatoid arthritis, such as reducing pain, inflammation, and stiffness, but they should be used as a complement to conventional treatments and not as a substitute.
Choice B is wrong because it implies that the client has no role in deciding their own treatment plan and that alternative therapies are not worth considering.
This may discourage the client from sharing their preferences and concerns with the provider.
Choice C is wrong because it suggests that online support groups are a reliable source of information about alternative remedies, which may not be true.
Online sources may contain inaccurate, misleading, or harmful information that could jeopardize the client’s health and safety.
Choice D is wrong because it encourages the client to try any therapy that fits their personal belief system, without considering the evidence, effectiveness, or potential risks of such therapies. Some alternative therapies may interact with medications, cause side effects, or worsen the condition.
Normal ranges for rheumatoid arthritis are not applicable in this question, as it is not asking about laboratory values or disease activity measures. However, some common tests used to diagnose and monitor rheumatoid arthritis include erythrocyte sedimentation rate (ESR), Creactive protein (CRP), rheumatoid factor (RF), anti-cyclic citrullinated peptide (anti-CCP) antibodies, and joint ultrasound or X-ray.
The normal ranges for these tests may vary depending on the laboratory and the method used.
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