The nurse is completing a sterile dressing change on a client. During the procedure, the client reaches down and touches the contents of the open dressing kit. What is the nurse's next action?

Obtain a new sterile dressing kit

Wash the patient's hands

Continue changing the dressing

Restrain the patient's hands

Answer and Explanation

The Correct Answer is A

A. Obtain a new sterile dressing kit: If the patient touches sterile supplies, contamination has occurred, compromising the sterile field. To prevent infection, the nurse must discard the contaminated kit and use a new sterile dressing kit.

B. Wash the patient's hands: Washing hands improves hygiene but doesn’t re-sterilize already contaminated items. The dressing kit is no longer sterile, so washing hands alone is insufficient. Sterility must be restored with new supplies.

C. Continue changing the dressing: Proceeding with the contaminated supplies risks introducing pathogens into the wound, increasing infection risk. The sterile field must be maintained at all times.

D. Restrain the patient's hands: Restraining without assessing or explaining is not appropriate; it can cause distress and is not a first-line response to contamination during a sterile procedure.

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 B

Explanation

A. Complete the task quickly, then obtain PPE: This action risks exposure to infectious agents and violates infection control protocols. Speed does not justify unsafe practice.

B. Stop and obtain appropriate PPE: The nurse should immediately stop the task and put on the necessary PPE to protect themselves and prevent the spread of infection before proceeding.

C. Ask a colleague to perform the task: Transferring the task does not address the nurse’s responsibility to maintain safety and infection control. The nurse must follow proper protocols personally.

D. Leave PPE in the room for the next person: PPE should be donned and doffed properly for each use and not left unattended or assumed to be for others’ use, which can lead to contamination or improper use.

A. based on the conversation with the patient, the patient is unhappy with care B. upon interaction with the patient, the patient seems angry today C. the patient is angry, unsatisfied with care, and wants to go home D. patient states. “I hate this place want to go home. No one listens to me and my doctor has not been in to see me today"

Correct Answer is D

Explanation

A. based on the conversation with the patient, the patient is unhappy with care: This statement includes the nurse’s interpretation rather than the patient’s exact words and feelings, which is less objective for documentation.

B. upon interaction with the patient, the patient seems angry today: This phrase is subjective and vague, lacking specific patient statements or observable behaviors, making it less precise for clinical records.

C. the patient is angry, unsatisfied with care, and wants to go home: This summarizes the nurse’s opinion rather than providing direct quotes or factual observations, which is not ideal for accurate documentation.

D. patient states, “I hate this place. I want to go home. No one listens to me, and my doctor has not been in to see me today.”: This is a direct quote from the patient, providing clear, objective documentation of the patient’s feelings and statements.

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

The nurse is completing a sterile dressing change on a client. During the procedure, the client reaches down and touches the contents of the open dressing kit. What is the nurse's next action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse begins a task and then realizes that personal protective equipment (PPE) is needed. What is the correct action by the nurse?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

A nurse is conducting an interview for a health history. In addition to asking the client about medications being taken, what else should be asked to assess the risk for drug interactions?

The nurse is conducting an assessment of a client that has been admitted to a medical unit in the hospital for treatment of pneumonia. Which action will the nurse take when conducting the respiratory assessment of this client?

The nurse is preparing to administer a medication via a nasogastric tube. Which guideline is appropriate for the nurse to follow when administering a drug via this route?

A nurse is caring for a client who is sleeping for abnormally long periods of time. This condition may be caused by injury to which body structure?

A client who has to undergo a parathyroidectomy is worried about possibly having to wear a scarf around the neck after surgery. What nursing diagnosis should the nurse document in the care plan?

The nurse is assessing a client recently diagnosed with terminal lung cancer who states, "This can't be happening to me. Maybe the doctor made a mistake." Which stage of death and dying is the client exhibiting?

What location would the nurse assess for a pedal pulse?

A nurse is preparing to administer ceftriaxone 300 mg IM into the right vastus lateralis. Which of the following actions should the nurse take to locate the site of injection?