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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Report the injury to a nurse manager:
While reporting the incident is important, the immediate action to take is cleaning the affected area to minimize the risk of infection.
B. Wash the affected area with soap and water:
This is the immediate priority to reduce the risk of potential infection or transmission of any contaminants from the needlestick injury.
C. Report the needle stick to the infection control department:
Reporting the incident is essential, but it should follow the immediate step of cleaning the affected area to prevent infection.
D. Scrub the area with hand sanitizer for a full 2 minutes:
Hand sanitizer may not be as effective as soap and water in removing contaminants from a needlestick injury site. Washing with soap and water is more appropriate for cleaning the area.
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.
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