Nokea
The nurse is changing a dressing. Which event indicates a break in sterile technique?
- A. The nurse opens the sterile dressing set by opening the first flap away from herself.
- B. The nurse turns around when answering a question asked by the client in the other bed.
- C. The nurse opens the dressing set on the overbed table.
- D. The nurse pours sterile saline into the container in the dressing set.
Correct Answer: B
Rationale: Turning around risks contaminating the sterile field by passing non-sterile areas over it. Opening flaps away, using the table, or pouring saline maintain sterility.
You may also like to solve these questions
A parent tells the nurse that their 6 year-old child who normally enjoys school, has not been doing well since the grandmother died 2 months ago. Which statement most accurately describes thoughts on death and dying at this age?
- A. Death is personified as the bogeyman or devil
- B. Death is perceived as being irreversible
- C. The child feels guilty for the grandmother's death
- D. The child is worried that he, too, might die
Correct Answer: A
Rationale: Death is personified as the bogeyman or devil. Personification of death is typical of this developmental level.
A child and his family were exposed to Mycobacterium tuberculosis about 2 months ago, to confirm the presence or absence of an infection, it is most important for all family members to have a
- A. Chest x-ray
- B. Blood culture
- C. Sputum culture
- D. PPD intradermal test
Correct Answer: D
Rationale: PPD intradermal test. The administration of the PPD intradermal test determines the presence of the infection with the Mycobacterium tuberculosis organism. It is effective at 3 to 6 weeks after the initial infection.
The nurse is assessing a 7-year-old client who was recently admitted with nausea, vomiting, severe right lower quadrant pain, and an elevated WBC count. Which of the following statements by the client would be a priority to follow up?
- A. I feel so tired.
- B. I am hungry and I want to eat.
- C. My stomach does not hurt anymore.
- D. I do not like hospitals and I want to go home.
Correct Answer: C
Rationale: Resolution of pain (C) in suspected appendicitis may indicate perforation, a surgical emergency, requiring urgent follow-up. Fatigue (A), hunger (B), and dislike of hospitals (D) are less critical.
The nurse has been teaching a woman who has iron deficiency anemia. Which menu, if selected, indicates that the woman understands her dietary instructions?
- A. Applesauce, green beans, bread, and butter
- B. Peanut butter and jelly sandwich, carrots, and milk
- C. Broccoli, spinach salad with tomatoes, and orange juice
- D. Macaroni and cheese, pickles, and hot chocolate
Correct Answer: C
Rationale: Broccoli, spinach, and orange juice (vitamin C enhances iron absorption) are iron-rich, ideal for anemia. Other menus lack sufficient iron sources.
The nurse is observing a staff member talking with the parent of a pediatric client. The parent is crying and states, 'I do not know what to do about this situation with my child.' The staff member responds, 'I am sure you will do the right thing.' The nurse should recognize that the staff member's response
- A. expresses interest in the parent's concern
- B. demonstrates respect for the parent's privacy
- C. devalues the parent's feelings and gives false reassurance
- D. conveys empathy toward the parent and promotes self-confidence
Correct Answer: C
Rationale: The response (C) dismisses the parent's distress and provides false reassurance, lacking empathy. It does not express interest (A), respect privacy (B), or convey empathy (D).