Nokea
A nurse is preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take.
- A. Grasp the outermost flap of the sterile kit while opening away from the body.
- B. Open the innermost lower flap of the sterile kit while standing away from the sterile field.
- C. Open each side flap of the sterile kit individually while pulling to the side.
- D. Prepare a dry work surface above the waist level.
- E. Open the outside cover of the sterile kit and remove the dust cover.
Correct Answer: D,E,A,C,B
Rationale: D: Set up surface. E: Remove cover. A: Open outermost flap. C: Open side flaps. B: Open innermost flap maintains sterility.
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The findings in the client's medical record indicate ___ and ___.
- A. Hyperglycemia
- B. Dehydration
Correct Answer: A,B
Rationale: Hyperglycemia: Symptoms of lethargy, thirst, and frequent urination with parenteral nutrition suggest elevated glucose levels. Dehydration: Thirst and frequent urination indicate fluid loss, a risk with parenteral nutrition if not balanced.
Which of the following actions should the nurse take to promote the client's respiratory status? Select all that apply.
- A. Encourage the client to splint the abdomen when coughing.
- B. Administer acetaminophen.
- C. Administer ondansetron.
- D. Remind the client to use the incentive spirometer five times per hr.
- E. Encourage the client to cough and deep breathe.
- F. Plan to ambulate the client 30 min after the next analgesic is administered.
Correct Answer: A,D,E,F
Rationale: A: Splinting reduces pain during coughing. D: Incentive spirometry prevents atelectasis. E: Coughing and deep breathing clear secretions. F: Ambulation post-analgesic promotes lung expansion.
A nurse is planning to obtain a client's oxygen saturation. Which of the following might influence the result of this test?
- A. The client has an elevated hemoglobin level.
- B. The client is wearing nail polish.
- C. The client has a fever.
- D. The client is wearing a ring.
Correct Answer: B
Rationale: Nail polish, especially dark colors, can block the pulse oximeter sensor, affecting accuracy.
A nurse is inserting an indwelling urinary catheter for a male client. After inserting the catheter 15 cm (6 in), the nurse feels resistance and no urine flows through the catheter. Which of the following actions should the nurse take?
- A. Apply lidocaine gel to the urethra.
- B. Twist the catheter gently.
- C. Inflate the catheter's balloon.
- D. Lower the penis to a 45° angle.
Correct Answer: B
Rationale: Gently twisting the catheter may navigate past resistance, often due to the prostatic urethra.
A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse plan to take?
- A. Use a 10-mL syringe filled with cleansing solution.
- B. Hold the syringe tip 2.5 cm (1 in) above the upper end of the wound.
- C. Cleanse the wound with cotton balls.
- D. Dry the wound bed with gauze squares.
Correct Answer: B
Rationale: Holding the syringe 2.5 cm above ensures effective irrigation without contamination.