Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is preparing to complete a sterile dressing change for a client's wound. Which of the following actions should the nurse take first?
A. Open the flap on the sterile kit nearest to the nurse and place the flap on the work surface.
B. Open the side flap of the sterile kit, allowing it to lie flat on the work surface.
C. Open the outermost flap of the sterile kit away from the nurse's body
Rationale: The nurse should open the outermost flap of the sterile kit away from their body first, as this will prevent contamination of their clothing or hands by touching any part of the inside surface or contents of the kit. The nurse should then open each side flap by grasping only its outer edge and pulling it toward them. The nurse should then open the flap nearest to them by grasping only its outer edge and pulling it toward them. The nurse should then apply sterile gloves before touching any part of the inside surface or contents of the kit.
D. Apply sterile gloves.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Proctored Exam. Take the full exam now
Full Explanation
The correct answer is C. Open the outermost flap of the sterile kit away from the nurse's body.
Rationale: The nurse should open the outermost flap of the sterile kit away from their body first, as this will prevent contamination of their clothing or hands by touching any part of
the inside surface or contents of the kit. The nurse should then open each side flap by grasping only its outer edge and pulling it toward them. The nurse should then open the flap nearest to them by grasping only its outer edge and pulling it toward them. The nurse should then apply sterile gloves before touching any part of the inside surface or contents of the kit.
Similar Questions
A nurse is caring for a client who has schizophrenia and is taking an antipsychotic medication. Which of the following screening tools should the nurse use to identify tardive dyskinesia?
A. Mental Status Examination
B. Brief Psychiatric Rating Scale
C. Patient Health Questionnaire-9
D. Abnormal Involuntary Movement Scale
Rationale: The Abnormal Involuntary Movement Scale is a diagnostic tool that assesses the severity of tardive dyskinesia, a disorder that results in involuntary repetitive body movements caused by long-term use of antipsychotic drugs.
Full Explanation
Answer: D. Abnormal Involuntary Movement Scale
Rationale: The Abnormal Involuntary Movement Scale is a diagnostic tool that assesses the severity of tardive dyskinesia, a disorder that results in involuntary repetitive body movements caused by long-term use of antipsychotic drugs.
A nurse in an acute care setting is assisting in collecting client information to include in a referral for a physical therapist. Which of the following information should the nurse plan to include?
A. Physical assessment findings
Rationale: Physical assessment findings are relevant information for a physical therapist, as they provide information about the client's mobility, strength, balance, coordination, pain, and functional status.
B. Family medical history
C. Medications taken prior to admission
D. Medical health insurance claims
Full Explanation
Answer: A. Physical assessment findings
Rationale: Physical assessment findings are relevant information for a physical therapist, as they provide information about the client's mobility, strength, balance, coordination, pain, and functional status.
A nurse is caring for a client who has a prescription for warfarin. Which of the following laboratory tests should the nurse monitor?
A. Blood urea nitrogen
B. Triiodothyronine
C. Arterial blood gases
D. Prothrombin time
Rationale: Prothrombin time is a measure of how long it takes the blood to clot, which is affected by warfarin, an anticoagulant medication that prevents blood clots from forming or growing larger.
Full Explanation
Answer: D. Prothrombin time
Rationale: Prothrombin time is a measure of how long it takes the blood to clot, which is affected by warfarin, an anticoagulant medication that prevents blood clots from forming or growing larger.