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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. (Move the steps, placing them in the order of performance.)
- A. Open the innermost lower flap of the sterile kit while standing away from the sterile field.
- B. Open each side flap of the sterile kit individually while pulling to the side.
- C. Prepare a dry work surface above the waist level.
- D. Open the outside cover of the sterile kit and remove the dust cover.
- E. Grasp the outermost flap of the sterile kit while opening away from the body.
Correct Answer: C,D,E,B,A
Rationale: C: Set up surface. D: Open cover. E: Open outermost flap. B: Open side flaps. A: Open innermost flap maintains sterility.
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A nurse is collecting data from a client about bowel elimination. Which of the following statements by the client indicates a risk for impaired bowel elimination?
- A. I drink two hot cups of coffee each morning.
- B. I love to eat apples and black-eyed peas.
- C. I take a prescribed opioid pain medication at bedtime.
- D. I drink an average of 2,000 milliliters of water daily.
Correct Answer: C
Rationale: Opioids slow gastrointestinal motility, increasing the risk of constipation and impaired bowel elimination.
A nurse is contributing to a community center's in-service program about early detection of breast cancer. Which of the following recommendations should the nurse make for female clients who do not have a family history of breast cancer?
- A. You should start receiving mammograms as early as age 40.
- B. You should receive a breast ultrasound every 3 years after age 50.
- C. You should receive a breast examination from your provider each year after age 30.
- D. You should start performing monthly breast self-examinations at age 35.
Correct Answer: A
Rationale: Guidelines recommend mammograms starting at 40 for average-risk women.
A nurse is reinforcing teaching with a client about the use of a quad cane. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will move the cane forward 18 inches.
- B. I will hold the cane on my stronger side.
- C. I should wear shoes with smooth soles to help slide my weak leg forward.
- D. I should move my stronger leg forward before moving my weaker leg.
Correct Answer: B
Rationale: Holding the cane on the stronger side provides optimal support and balance for the weaker side.
A nurse is preparing to reinforce teaching with a client who has expressive aphasia. Which of the following actions should the nurse plan to take?
- A. Provide the teaching without expecting the client to respond.
- B. Determine the client's ability to use a communication board.
- C. Speak with a loud voice while providing the information.
- D. Avoid the use of facial gestures during the instructions.
Correct Answer: B
Rationale: A communication board aids clients with expressive aphasia in responding, enhancing understanding.
A nurse is caring for an adult client who has acute lymphocytic leukemia. The client is refusing blood products. Which of the following responses should the nurse make?
- A. You need to talk with your doctor about this.
- B. Not receiving blood will slow down your recovery.
- C. I understand that you decided not to receive blood products.
- D. Why are you refusing to receive blood products?
Correct Answer: C
Rationale: Acknowledging the refusal respects autonomy while opening dialogue.