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A nurse is caring for a client who requires a sterile dressing change. The nurse should recognize that the surgical field has been contaminated if which of the following actions occur?
- A. The handle of a pair of sterile scissors is resting 5 cm (2 in) from the field's edge.
- B. A pair of sterile forceps is allowed to rest in a container of sterile water on the field.
- C. Unnecessary sterile items are placed on the field.
- D. The sterile solution is poured with the bottle held over the field.
Correct Answer: D
Rationale: Pouring with the bottle over the field risks contamination from the non-sterile bottle.
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A nurse is caring for a client who has a new colostomy. The client refuses to participate in her ostomy care, saying, 'I'm not touching that thing.' Which of the following actions should the nurse take?
- A. Request that someone from the client's family participate in the care.
- B. Ask the client to explain her feelings.
- C. Explain why her participation is important.
- D. Tell the client that it is safe to touch her ostomy.
- E. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin.
Correct Answer: B
Rationale: Exploring feelings addresses emotional barriers, promoting eventual acceptance of care.
A home health nurse is reinforcing teaching about dietary needs with the child of a client. They state, 'I don't know what to do because they're not eating.' Which of the following responses should the nurse make?
- A. Why do you think they're not eating?
- B. Tell me more about what happens at mealtime.
- C. They may need a feeding tube.
- D. I'm sure it's nothing serious and their appetite will return soon.
Correct Answer: B
Rationale: Exploring mealtime details gathers specific data to address the eating issue effectively.
A nurse is reinforcing teaching with a client who has an ostomy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will cut an opening in the skin barrier that is 1â„2 inch larger than the stoma.
- B. I will press on the skin barrier for 30 seconds to ensure that it adheres.
- C. I will clean around the stoma with a moisturizing soap.
- D. I will apply a thin layer of talc powder around the stoma before placing the appliance.
Correct Answer: B
Rationale: Pressing the barrier for 30 seconds ensures adhesion, preventing leaks and skin irritation.
A nurse is reinforcing teaching with a client who is perimenopausal. Which of the following statements by the client indicates an understanding of the teaching?
- A. I might have headaches due to a decline in my estrogen levels.
- B. I can expect to have regular periods until I am in menopause.
- C. The best time to perform a breast self-examination is on the first day of my period.
- D. I should stop receiving Papanicolaou tests once I reach menopause.
Correct Answer: A
Rationale: Declining estrogen in perimenopause can cause headaches, reflecting hormonal changes.
A nurse is providing end-of-life care to a client who is experiencing dyspnea. Which of the following actions should the nurse take?
- A. Reposition the client once every 4 hr.
- B. Provide oral care to the client once every 8 hr.
- C. Place the head of the client's bed flat.
- D. Use a fan to circulate air in the client's room.
Correct Answer: D
Rationale: A fan improves air movement, easing dyspnea in end-of-life care.