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. After hemodialysis, a client with a history of chronic renal failure has just returned to the unit. What is the most important assessment for the nurse to make?

A. Auscultate the client's lung sounds.
B. Assess the client's blood pressure.
C. Monitor the client's weight.
D. Check the client's fistula for bruit and thrill.

Correct answer: D

Rationale: The most crucial assessment for the nurse to make after hemodialysis in a client with chronic renal failure is to check the client's fistula for bruit and thrill (D). This assessment is essential to ensure the patency of the fistula and adequate blood flow. Auscultating lung sounds (A), assessing blood pressure (B), and monitoring weight (C) are important assessments but are secondary to evaluating the fistula. Checking the fistula is vital as it directly impacts the effectiveness of the client's dialysis treatment and the patency of the vascular access, ensuring successful dialysis sessions.

3. When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that this is the first time the client has voided in 4 hours. Which action should the nurse take next?

A. Record the amount on the client's fluid output record.
B. Encourage the client to increase oral fluid intake.
C. Notify the healthcare provider of the findings.
D. Palpate the client's bladder for distention.

Correct answer: A

Rationale: The nurse should record the amount on the client's fluid output record because the 350 mL of pale yellow urine is a normal finding. This indicates appropriate urine output, so encouraging increased fluid intake or notifying the healthcare provider is not necessary at this time. Additionally, palpating the client's bladder for distention is not indicated based on the normal urine output observed.

4. A client is admitted with a diagnosis of acute pancreatitis. Which assessment finding is most indicative of this diagnosis?

A. Epigastric pain that radiates to the back.
B. Abdominal pain with guarding.
C. Nausea and vomiting.
D. Increased bowel sounds in all quadrants.

Correct answer: A

Rationale: Epigastric pain that radiates to the back (A) is the hallmark assessment finding of acute pancreatitis. The pancreas lies retroperitoneally in the upper abdomen, so inflammation often causes severe epigastric pain that radiates through to the back. While abdominal pain with guarding (B), nausea and vomiting (C), and increased bowel sounds (D) can also be present in acute pancreatitis, they are less specific and may be seen in various other gastrointestinal conditions. Therefore, the most indicative finding for acute pancreatitis is epigastric pain that radiates to the back.

5. A healthcare professional stops at a motor vehicle collision site to render aid until the emergency personnel arrive and applies pressure to a groin wound that is bleeding profusely. Later, the client has to have the leg amputated and sues the healthcare professional for malpractice. What is the most likely outcome of this lawsuit?

A. The Patient's Bill of Rights protects clients from malicious intents, so the healthcare professional could lose the case.
B. The lawsuit may be settled out of court, but the healthcare professional's license is likely to be revoked.
C. There will be no judgment against the healthcare professional, whose actions were protected under the Good Samaritan Act.
D. The client will win because the four elements of negligence (duty, breach, causation, and damages) can be proved.

Correct answer: C

Rationale: The Good Samaritan Act protects healthcare professionals who provide care in good faith and offer reasonable assistance in emergencies. This law shields them from malpractice claims, even if the outcome for the client is unfavorable. In this scenario, the healthcare professional is likely to be protected from judgment under the Good Samaritan Act. Choice A is incorrect because the situation does not involve the Patient's Bill of Rights, but rather the Good Samaritan Act. Choice B is incorrect as the license revocation is not a typical outcome in Good Samaritan cases. Choice D is incorrect as the Good Samaritan Act provides immunity from liability in such emergency situations.