Nokea
Select the basic sterile asepsis procedures that are accurate. Select all that apply:
- A. Sterile items ONLY are placed on the sterile field.
- B. The nurse must keep the sterile field below waist level.
- C. Coughing or sneezing over the sterile field contaminates the sterile field.
- D. The nurse must maintain a 1/2 inch border around the sterile field that is not sterile.
- E. Moisture and wetness contaminate the sterile field.
- F. Sterile masks are used by staff and the client when a sterile field is being set up and/or maintained
Correct Answer: A,C,E
Rationale: Sterile items only on the sterile field , coughing/sneezing contaminating the field , and moisture contaminating the field are accurate sterile asepsis principles. The sterile field must be above waist level (B is incorrect), a 1-inch border is standard (D is incorrect), and masks are not required for clients (F is incorrect).
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You measure your 2 year old client's vital signs as: • Respiratory rate: 32 breaths per minute • Pulse: 110 beats per minute • Blood pressure: 55/82. The mother asks you if these vital signs are normal. You should respond to this mother's question by stating:
- A. The respiratory rate is a little too fast but the other vital signs are normal.'
- B. The pulse rate is a little too fast but the other vital signs are normal.'
- C. The blood pressure is a little low but the other vital signs are normal.'
- D. All of these vital signs are normal for a child that is 2 years of age.'
Correct Answer: C
Rationale: For a 2-year-old, normal ranges are approximately: respiratory rate 20-30 breaths/min, pulse 80-130 beats/min, blood pressure ~90/55 mmHg. The blood pressure (55/82) is low (systolic is below normal), while the respiratory rate and pulse are within or slightly above normal ranges.
The nurse is assessing a client with a suspected cholecystitis. Which of the following findings is most indicative of this condition?
- A. Right upper quadrant pain.
- B. Left lower quadrant pain.
- C. Soft, nontender abdomen.
- D. Frequent loose stools.
Correct Answer: A
Rationale: Right upper quadrant pain is a hallmark sign of cholecystitis due to gallbladder inflammation.
A 9-month-old child has been diagnosed with an ear infection. The father asks what else to do to help his child. The nurse can tell the father:
- A. Your child should also take an antihistamine.'
- B. The antibiotic is the only medicine necessary.'
- C. The ear in the ears helps the discomfort.'
- D. Over-the-counter eardrops often are helpful.'
Correct Answer: B
Rationale: Antibiotics are the primary treatment for bacterial ear infections; antihistamines and eardrops are not typically recommended unless prescribed.
The nurse is assessing a client with a suspected stroke. Which of the following findings is most indicative of a stroke?
- A. Sudden unilateral weakness.
- B. Gradual onset of headache.
- C. Bilateral leg pain.
- D. Chronic fatigue.
Correct Answer: A
Rationale: Sudden unilateral weakness is a classic sign of stroke due to impaired blood flow to one side of the brain.
The nurse should assess the child with nephrotic syndrome for which of the following? Select all that apply.
- A. Normal blood pressure.
- B. Generalized edema.
- C. Normal serum lipid levels.
- D. No red blood cells in the urine.
- E. Elevated streptococcal antibody titers.
Correct Answer: B,D
Rationale: Nephrotic syndrome is characterized by generalized edema and no red blood cells in the urine. Blood pressure may be elevated, serum lipids are typically high, and streptococcal antibodies are not typically associated.