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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 stenile-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. When setting up a sterile field, it is essential to maintain sterility. By removing the cap and placing it sterile-side up on a clean surface, the nurse ensures that the inside of the cap, which will come into contact with the sterile solution, remains uncontaminated. Placing the cap sterile-side up prevents any potential contaminants from coming into contact with the solution. This practice follows aseptic technique guidelines to prevent the introduction of pathogens.
Choices B, C, and D are incorrect because they do not address the key principle of maintaining sterility. Placing sterile gauze over spilled solution (B) can introduce contaminants to the field, holding the bottle in the center (C) does not prevent contamination, and the orientation of the label (D) does not affect sterility.
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Which of the following actions should the nurse take?
- A. Monitor for the development of Koplik spots.
- B. Isolate the client from staff who are pregnant.
- C. Administer aspirin to the client
- D. Initiate airborne precautions
Correct Answer: B
Rationale: Pregnant women should avoid contact with individuals who have rubella due to the risk of congenital defects.
Which of the following findings indicates the newborn is experiencing withdrawal?
- A. Bulging fontanels
- B. Acrocyanosis
- C. Bradycardia
- D. Hypertonicity
Correct Answer: D
Rationale: The correct answer is D: Hypertonicity. This finding indicates the newborn is experiencing withdrawal because it is a common symptom of withdrawal from substances such as opioids or benzodiazepines. Hypertonicity refers to increased muscle tone, which can be observed through increased resistance to passive movement. It is a sign of central nervous system hyperirritability, often seen in newborns going through withdrawal. Bulging fontanels (A) are a sign of increased intracranial pressure. Acrocyanosis (B) is a normal finding in newborns and is due to immature circulation. Bradycardia (C) is a slow heart rate, which can be caused by various factors in newborns, not specifically indicative of withdrawal.
Which of the following actions should the nurse encourage the client and family to take as they adjust to their new roles?
- A. Implement firm but flexible boundaries in their relationship
- B. Encourage authoritative communication from the adult child
- C. Decrease socialization with extended relatives until roles are identified,
- D. Minimize open discussion regarding the changes to avoid embarrassment.
Correct Answer: A
Rationale: Boundaries foster healthy family dynamics during role adjustments.
Which of the following medications should the nurse administer?
- A. Bisacodyl 10 mg rectal suppository
- B. Magnesium hydroxide 30 mL PO
- C. Famotidine 20 mg PO
- D. Loperamide 4 mg PO
Correct Answer: A
Rationale: The correct answer is A: Bisacodyl 10 mg rectal suppository. Bisacodyl is indicated for immediate relief of constipation as a rectal suppository. It acts directly on the colon to stimulate peristalsis and promote bowel movement. The rectal route ensures faster onset of action compared to oral medications, making it suitable for a patient needing immediate relief. Magnesium hydroxide (B) is a laxative taken orally, which may not provide quick relief. Famotidine (C) is for acid reflux, not constipation. Loperamide (D) is an antidiarrheal agent, not appropriate for constipation.
Which of the following findings should the nurse expect?
- A. Spotting
- B. Nausea
- C. Polyhydramnios
- D. Uterine tenderness
Correct Answer: A
Rationale: The correct answer is A: Spotting. Spotting is a common finding in early pregnancy due to implantation bleeding or hormonal changes. It is often a normal occurrence, especially in the first trimester. Nausea (choice B) is another common finding in early pregnancy, known as morning sickness. Polyhydramnios (choice C) is an excessive accumulation of amniotic fluid and is not typically an expected finding. Uterine tenderness (choice D) can be a sign of infection or other issues, not a typical finding in early pregnancy.