The nurse on the progressive care unit is preparing to perform a sterile wet to dry dressing change on a client with a sacral pressure ulcer. The nurse notes that the sterile saline at the bedside is marked as opened 48 hours ago. What is the nurse’s priority action?

Discard the bottle of saline and obtain a new bottle

Lip the battle of saline over the trash before pouring into the field

Pour the saline at least 6 inches above the sterile field

Be sure the label is facing the palm before pouring

Answer and Explanation

The Correct Answer is A

A. Discard the bottle of saline and obtain a new bottle:

Sterility is crucial when performing a sterile procedure. If the saline solution has been opened for 48 hours, it may no longer be considered sterile. The nurse's priority is to use a fresh, sterile bottle of saline to ensure aseptic technique during the dressing change.

B. Lip the bottle of saline over the trash before pouring into the field:

Lipping the bottle over the trash is not a recommended practice. Pouring the saline over a sterile field is the appropriate way to maintain the sterility of the solution.

C. Pour the saline at least 6 inches above the sterile field:

While pouring from a height can help generate a flow without contamination, the priority in this situation is to address the sterility of the saline. It's crucial to start with a new, unopened bottle.

D. Be sure the label is facing the palm before pouring:

The orientation of the label is not the primary concern in this scenario. The primary concern is the sterility of the saline solution.

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Correct Answer is C

Explanation

A. 30 degrees:

This angle does not meet the criteria for a High Fowler's position, which requires a more upright position.

B. 15 to 20 degrees:

This angle is lower than what is generally considered as High Fowler's position. High Fowler's is a more upright position.

C. 90 degrees:

High Fowler's position involves elevating the head of the bed to 90 degrees. This position is often used for better lung expansion and respiratory function.

D. 45-60 degrees:

While this range is higher than a semi-Fowler's position, it is not as upright as the 90-degree elevation in a High Fowler's position.

A. Systolic pressure B. Pulse pressure C. Auscultatory gap D. Diastolic pressure

Correct Answer is D

Explanation

A. Systolic pressure:

The first sound heard during blood pressure measurement corresponds to the systolic pressure, the pressure in the arteries when the heart is contracting.

B. Pulse pressure:

Pulse pressure is the numerical difference between the systolic and diastolic pressures but is not specifically represented by a sound in blood pressure measurement.

C. Auscultatory gap:

An auscultatory gap is a temporary disappearance of sounds during blood pressure measurement, typically occurring between the systolic and diastolic pressures. It is not directly associated with the second sound.

D. Diastolic pressure:

The second sound heard corresponds to the closure of the aortic valve, marking the beginning of diastole. This sound represents the diastolic pressure, which is the pressure in the arteries when the heart is at rest.

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The nurse on the progressive care unit is preparing to perform a sterile wet to dry dressing change on a client with a sacral pressure ulcer. The nurse notes that the sterile saline at the bedside is marked as opened 48 hours ago. What is the nurse’s priority action?

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Correct Answer is D

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The nurse on the progressive care unit is preparing to perform a sterile wet to dry dressing change on a client with a sacral pressure ulcer. The nurse notes that the sterile saline at the bedside is marked as opened 48 hours ago. What is the nurse’s priority action?