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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?
- A. Remove the cap and place it sterile-side up on a clean surface.
- B. Place sterile gauze over areas of spilled solution within the sterile field.
- C. Hold the bottle in the center of the sterile field when pouring the solution.
- D. Hold the irrigation solution bottle with the label facing away from the palm of the hand.
Correct Answer: A
Rationale: The correct answer is A: Remove the cap and place it sterile-side up on a clean surface. This is essential to maintain the sterility of the solution and prevent contamination. Placing the cap sterile-side up ensures that the inside of the cap, which will come in contact with the solution again, remains sterile. Placing it on a clean surface prevents contamination from the surface. Options B, C, and D do not directly address maintaining the sterility of the solution. Option B is about spill management within the sterile field, which is important but not the primary concern when pouring the solution. Holding the bottle in the center (Option C) or with the label facing away (Option D) does not directly impact the sterility of the solution.
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A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?
- A. Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter.
- B. Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min
- C. Make sure the reservoir bag of a partial rebreathing mask remains deflated.
- D. Use petroleum jelly to lubricate the client's nares, face, and lips.
Correct Answer: B
Rationale: The correct answer is B: Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. This is the correct action because excessive oxygen flow can lead to oxygen toxicity and respiratory depression in patients. Nasal cannulas are commonly used for oxygen therapy and a flow rate of more than 6 L/min can cause discomfort and dryness of the nasal passages. It is important to adhere to evidence-based practice guidelines to ensure patient safety and well-being.
Choice A is incorrect because aligning the flow rate with the top of the ball inside the flow meter is not a reliable method for regulating oxygen flow. Choice C is incorrect as the reservoir bag of a partial rebreathing mask should remain inflated to ensure an adequate oxygen supply. Choice D is incorrect as petroleum jelly should not be used in oxygen therapy due to the risk of flammability.
A nurse in a provider's office is caring for a client who asks about using acupuncture to manage his osteoarthritis pain. The nurse should identify which of the following conditions as a contraindication for receiving this treatment?
- A. Hypertension
- B. Obesity
- C. Hypothyroidism
- D. Herpes zoster
Correct Answer: D
Rationale: The correct answer is D: Herpes zoster. Acupuncture involves inserting needles into specific points on the body to alleviate pain. Herpes zoster, also known as shingles, is a viral infection that causes a painful rash. The presence of open sores or active infection in the area where acupuncture needles would be inserted can lead to complications such as spreading the virus or causing pain. Therefore, it is contraindicated to receive acupuncture treatment when a client has active herpes zoster.
Hypertension (A), obesity (B), and hypothyroidism (C) are not contraindications for acupuncture treatment. Hypertension may actually benefit from acupuncture as it can help reduce stress and improve circulation. Obesity and hypothyroidism do not pose any direct risks for receiving acupuncture treatment.
A nurse is preparing to insert an IV catheter for a client. Which of the following actions should the nurse plan to take?
- A. Choose a vein that is palpable and straight.
- B. Elevate the client's arm prior to insertion.
- C. Apply a tourniquet below the venipuncture site.
- D. Select a site on the client's dominant arm.
Correct Answer: A
Rationale: Correct Answer: A. Choose a vein that is palpable and straight.
Rationale: Selecting a palpable and straight vein ensures successful insertion and reduces the risk of complications like infiltration or phlebitis. A straight vein allows for easier catheter insertion and reduces the chance of vein damage. Palpability helps in accurately locating the vein for successful cannulation.
Summary of Other Choices:
B: Elevating the client's arm may help distend the veins, but it is not a necessary step for IV catheter insertion.
C: Applying a tourniquet below the venipuncture site can help visualize veins better but is not crucial for successful IV catheter insertion.
D: Selecting the site on the client's dominant arm is not necessary. The nurse should choose the best vein regardless of the arm dominance to ensure successful cannulation.
A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take?
- A. Assist the client into a prone position.
- B. Place a sleeve over the top of each leg with the opening at the knee.
- C. Make sure two fingers can fit under the sleeves.
- D. Set the ankle pressure at 65 mm Hg.
Correct Answer: C
Rationale: The correct answer is C: Make sure two fingers can fit under the sleeves. This is correct because the proper fit of sequential compression sleeves is essential for effective use. Ensuring that two fingers can fit under the sleeves ensures that they are not too tight, which could impede circulation.
Explanation for why the other choices are incorrect:
A: Assisting the client into a prone position is not necessary for applying sequential compression sleeves.
B: Placing a sleeve over the top of each leg with the opening at the knee is incorrect as the opening should be at the ankle.
D: Setting the ankle pressure at 65 mm Hg is incorrect as pressure settings should be determined based on the individual's needs and the healthcare provider's orders.
A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?
- A. A client who is ambulatory and receiving oxygen
- B. A client who has a fracture and is in balance suspension traction
- C. A client who is bedridden and wears a hearing aid
- D. A client who uses a wheelchair and is confused
Correct Answer: A
Rationale: The correct answer is A: A client who is ambulatory and receiving oxygen should be evacuated first during a fire. This client has the highest risk due to the combination of mobility impairment and oxygen use, which increases the potential for rapid deterioration in a fire emergency. Oxygen supports combustion, making this client more vulnerable to fire-related injuries.
Choice B: A client with a fracture in balance suspension traction is stable and can wait for evacuation. Choice C: A bedridden client with a hearing aid can still hear evacuation instructions and wait for assistance. Choice D: A confused client in a wheelchair may require assistance but is not at immediate risk like the ambulatory client with oxygen.