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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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A nurse is providing discharge teaching about home care of a surgical incision to a client who speaks a different language from the nurse. The nurse is communicating with the client using an interpreter. Which of the following actions should the nurse take?
- A. Speak slowly when talking to the interpreter.
- B. Pause in the middle of sentences
- C. Speak directly to the client
- D. Use gestures to convey meaning
Correct Answer: C
Rationale: The correct answer is C: Speak directly to the client. This is important because even when using an interpreter, the nurse should maintain eye contact and address the client directly to establish trust and ensure the message is accurately conveyed. Speaking slowly (choice A) may be helpful, but it is not as crucial as direct communication. Pausing in the middle of sentences (choice B) could lead to confusion. Using gestures (choice D) may not always accurately convey the intended message. Therefore, speaking directly to the client is the most effective way to ensure clear communication and understanding.
Which of the following is an appropriate action by the nurse?
- A. Suggest rinsing his mouth with an alcohol-based mouth wash
- B. Provide humidification of the room air.
- C. Offer the client saltine crackers between meals
- D. Instruct the client on the use of esophageal speech
Correct Answer: B
Rationale: The correct answer is B: Provide humidification of the room air. Humidification helps to moisturize the air, making it easier for the client to breathe, especially if they have dry mouth or throat. This can improve comfort and prevent irritation. Choice A is incorrect because alcohol-based mouthwash can further dry out the mouth. Choice C is incorrect as saltine crackers can exacerbate dry mouth. Choice D is incorrect as esophageal speech is not related to addressing dry mouth.
A home health nurse is caring for a child who has Lyme disease. Which of the following is an appropriate action for the nurse to take
- A. Ensure the state health department has been notified
- B. Administer antitoxin.
- C. Educate the family to avoid sharing personal belongings
- D. Assess for skin necrosis
Correct Answer: A
Rationale: Correct Answer: A: Ensure the state health department has been notified.
Rationale:
1. Lyme disease is a reportable infectious disease, so notifying the state health department is crucial for tracking and controlling its spread.
2. Reporting to the health department allows for proper surveillance and monitoring of the disease in the community.
3. By notifying the health department, appropriate public health interventions can be implemented to prevent further cases.
Summary of Incorrect Choices:
B: Administer antitoxin - Lyme disease is caused by a bacterium, not a toxin, so antitoxin administration is not appropriate.
C: Educate the family to avoid sharing personal belongings - While important for hygiene, it does not directly address the management of Lyme disease.
D: Assess for skin necrosis - Skin necrosis is not a common manifestation of Lyme disease, so this action is not a priority in caring for a child with Lyme disease.
Which of the following foods should the nurse suggest the client include in their diet?
- A. Cheese
- B. Red meat
- C. Canned black beans
- D. Fish
Correct Answer: D
Rationale: Fish is low in saturated fats and beneficial for cardiovascular health.
Which of the following manifestations should the nurse expect?
- A. Shortness of breath
- B. Dizziness
- C. Epistaxis
- D. Headache
Correct Answer: B
Rationale: Dizziness reflects reduced circulating volume.