what action should the nurse implement when adding sterile liquids to a sterile field

HESI RN

HESI Fundamentals

1. What action should be taken when adding sterile liquids to a sterile field?

A. Use an expired sterile liquid if the bottle is sealed and unopened.
B. Consider the sterile field contaminated if it becomes wet during the procedure.
C. Remove the container cap and place it with the inside facing up on the sterile field.
D. Hold the container low and pour the solution into a receptacle at the front of the sterile field.

Correct answer: B

Rationale: If a sterile field becomes wet or damp during a procedure, it is considered contaminated as moisture can allow organisms to wick from the surface and compromise the sterility of the field. It is essential to maintain the integrity of the sterile field to prevent infections and ensure patient safety.

2. The UAP is positioning a newly admitted client with a seizure disorder in a supine position. The UAP is placing soft pillows along the side rails. What action should the nurse take?

A. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows
B. Ensure that the UAP has placed pillows effectively to protect the client
C. Ask the UAP to use some pillows to prop the client in a side-lying position
D. Assume responsibility for placing the pillows while the UAP completes another task

Correct answer: A

Rationale: To prevent the risk of suffocation, soft blankets are preferred over pillows for padding side rails in clients with seizure disorders. Pillows can pose a suffocation hazard, especially during a seizure episode when the client's movements may be uncontrolled. Instructing the UAP to use soft blankets instead of pillows is crucial for ensuring the client's safety. Choice B is incorrect because pillows can be hazardous during a seizure. Choice C is incorrect as side-lying position may not be appropriate for a client with a seizure disorder. Choice D is incorrect as it does not address the safety concern related to using pillows.

3. An older adult who recently began self-administration of insulin calls the nurse daily to review the steps that should be taken when giving an injection. The nurse has assessed the client's skills during two previous office visits and knows that the client is capable of giving the daily injection. Which response by the nurse is likely to be most helpful in encouraging the client to assume total responsibility for the daily injections?

A. I know you are capable of giving yourself the insulin.
B. Giving yourself the injection seems to make you nervous.
C. When I watched you give yourself the injection, you did it correctly.
D. Tell me what you want me to do to help you give yourself the injection at home.

Correct answer: C

Rationale: Choice C is the correct answer because focusing on the client's demonstrated ability to self-administer the injection is likely to reinforce his level of competence without sounding punitive. By acknowledging the client's correct performance during the self-injection, the nurse can boost the client's confidence, encouraging him to assume total responsibility for the daily injections. Choices A, B, and D do not directly highlight the client's competence in self-administration, which may not be as effective in promoting independent self-care.

4. During a routine assessment, an obese 50-year-old female client expresses concern about her sexual relationship with her husband. Which is the best response by the nurse?

A. Reassure the client that many obese individuals have concerns about sex.
B. Remind the client that sexual relationships can be maintained regardless of weight.
C. Determine the frequency of sexual intercourse.
D. Ask the client to talk about specific concerns.

Correct answer: D

Rationale: The best response for the nurse is to ask the client to talk about specific concerns. This approach provides an opportunity for the client to express her worries openly, allowing the nurse to gather more detailed information for a comprehensive assessment and to address the client's concerns effectively.

5. When assisting a client with right-sided hemiplegia to get into a wheelchair, how should the nurse position the wheelchair?

A. On the left side of the bed facing the foot of the bed.
B. On the right side of the bed facing the head of the bed.
C. Perpendicular to the bed on the right side.
D. Facing the bed on the left side of the bed.

Correct answer: A

Rationale: Positioning the wheelchair on the left side of the bed facing the foot of the bed is the correct approach when assisting a client with right-sided hemiplegia. Placing the wheelchair on the left side allows the client to stand on their unaffected foot and pivot to sit down safely. This positioning facilitates a smoother transfer and helps maintain the client's stability during the process. Choice B is incorrect because positioning the wheelchair on the right side facing the head of the bed would make it challenging for the client to transfer due to their right-sided hemiplegia. Choice C is incorrect as placing the wheelchair perpendicular to the bed on the right side may not provide the necessary space and angle for a safe transfer. Choice D is incorrect as facing the bed on the left side of the bed does not provide the optimal position for the client to transfer from the bed to the wheelchair effectively.