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A nurse is setting up a sterile field in a client's room. Which of the following actions should the nurse take?
- A. Placing the cap of a sterile solution on a clean surface with the inside facing down.
- B. Placing a sterile instrument within 1.3 cm (0.5 in) of the edge of the sterile field.
- C. Opening the top flap of the sterile tray package away from their body.
- D. Dropping sterile objects onto the field from a height of 5 cm (2 in).
Correct Answer: C
Rationale: Opening the flap away prevents contamination from the nurse’s body.
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A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about the proper use of restraints. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
- A. Pad bony prominences before applying a restraint.
- B. Tie the ends of the restraint to the client's bed rail.
- C. Use a square knot to secure the client's restraint to the bed.
- D. Observe the client's skin integrity every 2 hr.
- E. Ensure that 2 fingers can be placed between the restraint and the client.
Correct Answer: A,D,E
Rationale: A: Protects skin. D: Monitors for issues. E: Prevents overly tight restraints.
A nurse is preparing to remove an NG tube for a client who is postoperative following colon surgery. In which sequence should the nurse perform the following steps?
- A. Apply clean gloves.
- B. Disconnect the tube from the suction device.
- C. Instill 50 mL of air into the tube.
- D. Ask the client to take a deep breath.
- E. Pinch and withdraw the tube.
Correct Answer: A,B,C,D,E
Rationale: A: Gloves ensure hygiene. B: Disconnect suction. C: Air clears tube. D: Breath aids removal. E: Pinch prevents leakage.
A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.)
- A. A client receives burns from a heating pad.
- B. A client reports being dissatisfied with the temperature of the meals provided.
- C. A client becomes disoriented and falls out of bed.
- D. A client’s visitor becomes dizzy and faints in the client's room.
- E. A client is unable to afford the physical therapy that the provider recommends.
Correct Answer: A,C,D
Rationale: A: Injury requires reporting. C: Fall indicates safety issue. D: Visitor incident needs documentation.
A nurse is caring for a client who refuses their morning dose of antihypertensive medication. The client tells the nurse, 'I'm not going to take this medication because it makes me sick and dizzy.' Which of the following actions should the nurse take first?
- A. Document the refusal in the client's medical record.
- B. Return the medication to the medication cabinet.
- C. Inform the client of the potential consequences of their refusal.
- D. Notify the provider of the client's refusal.
Correct Answer: C
Rationale: Informing about consequences first respects autonomy and may encourage compliance.
A nurse is preparing to clean a blood spill on a bedside table. Which of the following solutions should the nurse plan to use?
- A. Isopropyl alcohol.
- B. Hydrogen peroxide.
- C. Chlorhexidine gluconate.
- D. Chlorine bleach.
Correct Answer: D
Rationale: Chlorine bleach effectively kills bloodborne pathogens like HIV and hepatitis B.