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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 parish nurse is leading a support group for clients whose family members have committed suicide. Which of the following strategies should the nurse plan to use during the group session?
- A. Encourage clients to establish a timeline for their own grieving process.
- B. Initiate a discussion with clients about ways to cope with changes in family dynamics.
- C. Assist clients in identifying ways suicide could have been prevented
- D. Discourage clients from sharing negative aspects of their relationship with the deceased person
Correct Answer: B
Rationale: The correct answer is B: Initiate a discussion with clients about ways to cope with changes in family dynamics. This is the most appropriate strategy as it addresses the immediate impact of the suicide on family dynamics and helps clients develop coping mechanisms. Discussing coping strategies can empower clients to navigate the difficult changes they are facing.
A: Encouraging clients to establish a timeline for their own grieving process may not be helpful as each individual grieves differently and timelines can vary significantly.
C: Assisting clients in identifying ways suicide could have been prevented may lead to feelings of guilt and self-blame, which can be harmful to the healing process.
D: Discouraging clients from sharing negative aspects of their relationship with the deceased person can hinder the expression of emotions and the processing of complex feelings related to the loss.
A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take?
- A. Document the client's behavior prior to being placed in seclusion,
- B. Assess the client's behavior once every hour
- C. Offer fluids every 2 hr.
- D. Discuss with the client his inappropriate behavior prior to seclusion
Correct Answer: A
Rationale: The correct answer is A: Document the client's behavior prior to being placed in seclusion. This is important for legal and clinical reasons as it provides a clear record of the client's behavior leading up to seclusion, ensuring transparency and accountability. Assessing behavior once every hour (choice B) may not be sufficient for monitoring the client's condition in seclusion. Offering fluids every 2 hours (choice C) is important for hydration but not directly related to seclusion. Discussing inappropriate behavior with the client (choice D) may escalate the situation and is not recommended in this scenario.
Which of the following information should the nurse include in the teaching?
- A. Take mineral oil at bedtime
- B. Decrease insoluble fiber intake
- C. Drink 1,5 L of fluids each day.
- D. Increase exercise activity.
Correct Answer: D
Rationale: The correct answer is D: Increase exercise activity. This is important for promoting regular bowel movements and overall gastrointestinal health. Exercise helps stimulate the digestive system and aids in relieving constipation. Taking mineral oil (choice A) can interfere with nutrient absorption and is not recommended for long-term use. Decreasing insoluble fiber intake (choice B) can worsen constipation as fiber helps promote bowel regularity. Drinking 1.5 L of fluids each day (choice C) is important for hydration but alone may not be sufficient to improve bowel function. Increasing exercise activity (choice D) is the most effective way to promote healthy digestion and prevent constipation.
Which of the following actions should the nurse plan to take?
- A. The nurse should use a filter needle to withdraw the medication.
- B. The nurse should break the neck of the ampule toward their body
- C. The nurse should use the same needle to draw up and inject the client
- D. The nurse should dispose of the ampule in the trash can.
Correct Answer: A
Rationale: The correct answer is A: The nurse should use a filter needle to withdraw the medication. This is the correct action as filter needles help prevent the introduction of particulate matter or impurities into the medication, ensuring patient safety. Using a filter needle also reduces the risk of needlestick injuries and contamination.
Choice B is incorrect as breaking the neck of the ampule towards the body increases the risk of injury due to glass shards flying towards the nurse. Choice C is incorrect as it violates safe medication administration practices by risking contamination. Choice D is incorrect as ampules should be disposed of in a sharps container, not the trash can.
Which of the following actions should the nurse take?
- A. Limit oral feedings to 30 min in length.
- B. Check the infant's oxygen saturation every 6 hr
- C. Place the infant in the prone position for naps
- D. Weigh the infant every other day.
Correct Answer: A
Rationale: Limiting feeding durations conserves energy for infants with heart failure.