Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is preparing to set up a sterile field. Which of the following actions should the nurse take?
A. Place the sterile field at the level of the nurse's hips.
Place the sterile field at the level of the nurse's hips:This is incorrect. The sterile field should be placed at a waist or chest level to maintain its sterility. Placing it at the level of the nurse's hips increases the risk of contamination from airborne particles, clothing, or unsterile surfaces.
B. Pour liquids into containers outside the sterile field.
Pour liquids into containers outside the sterile field:This is incorrect. Pouring liquids into containers outside the sterile field may lead to contamination. All actions involving sterile items should be performed within the sterile field to maintain its integrity and prevent the introduction of microorganisms.
C. Hold bottles of sterile solution with the label in the palm of the hand.
Hold bottles of sterile solution with the label in the palm of the hand:This is correct. This prevents label from becoming wet and illegible.
D. Open the outermost flap of the sterile kit toward the body.
Open the outermost flap of the sterile kit toward the body:This is incorrect. When opening a sterile kit, the nurse should open the outermost flap first and away from the body. This minimizes the risk of reaching over the sterile field, reducing the chance of accidental contamination.
This question is an excerpt from Nurse Dive's nursing test bank - RN FUNDAMENTALS 2023 PROCTORED EXAM. Take the full exam now
Full Explanation
A. Place the sterile field at the level of the nurse's hips:
This is incorrect. The sterile field should be placed at a waist or chest level to maintain its sterility. Placing it at the level of the nurse's hips increases the risk of contamination from airborne particles, clothing, or unsterile surfaces.
B. Pour liquids into containers outside the sterile field:
This is incorrect. Pouring liquids into containers outside the sterile field may lead to contamination. All actions involving sterile items should be performed within the sterile field to maintain its integrity and prevent the introduction of microorganisms.
C. Hold bottles of sterile solution with the label in the palm of the hand:
Hold bottles of sterile solution with the label in the palm of the hand:This is correct. This prevents label from becoming wet and illegible.
D. Open the outermost flap of the sterile kit toward the body:
Open the outermost flap of the sterile kit toward the body:This is incorrect. When opening a sterile kit, the nurse should open the outermost flap first and away from the body. This minimizes the risk of reaching over the sterile field, reducing the chance of accidental contamination.
Similar Questions
A nurse is preparing to administer medications to a client. At which of the following times should the nurse compare the medication administration record and the medication label? (Select all that apply.)
A. When preparing the medication dosage
Comparing the medication administration record with the medication label during preparation helps ensure the correct medication and dosage are being used.
B. Directly before administering the medication
This final check ensures that the medication being given matches the prescription and the right patient, minimizing the risk of errors.
C. When reconciling counts of controlled substances
This is important for ensuring accurate inventory but is not related to verifying medication administration.
D. When removing the medication from the medication drawer
This initial check ensures that the medication being retrieved is the correct one as per the medication administration record.
E. At the end of the shift
This is not a time for verifying medication records and labels; it’s more related to end-of-shift documentation and handoff.
Full Explanation
Correct responses:
A. When preparing the medication dosage: Comparing the medication administration record with the medication label during preparation helps ensure the correct medication and dosage are being used.
B. Directly before administering the medication: This final check ensures that the medication being given matches the prescription and the right patient, minimizing the risk of errors.
D. When removing the medication from the medication drawer: This initial check ensures that the medication being retrieved is the correct one as per the medication administration record.
The other options are not directly related to verifying the medication administration record against the medication label:
C. When reconciling counts of controlled substances: This is important for ensuring accurate inventory but is not related to verifying medication administration.
E. At the end of the shift: This is not a time for verifying medication records and labels; it’s more related to end-of-shift documentation and handoff.
A home health nurse is assessing the home environment of an older adult client who has osteoporosis. For which of the following findings should the nurse intervene?
A. The hot water heater is set to 47° C (117° F).
This temperature is within a safe range to prevent burns while ensuring adequate hot water for hygiene.
B. Grab bars are installed in the shower.
Grab bars provide support and help prevent falls in older adults, especially those with osteoporosis who are at higher risk for fractures.
C. There is an area rug covering a tile floor.
Area rugs are a significant tripping hazard, especially for older adults with osteoporosis, as a fall could lead to fractures. The nurse should intervene to recommend removing or securing the rug to reduce the risk of falls.
D. Prescriptions are stored in a medication organizer.
A medication organizer helps older adults manage their medications effectively and reduces the risk of missed or incorrect doses.
Full Explanation
A. The hot water heater is set to 47° C (117° F). This temperature is within a safe range to prevent burns while ensuring adequate hot water for hygiene.
B. Grab bars are installed in the shower. Grab bars provide support and help prevent falls in older adults, especially those with osteoporosis who are at higher risk for fractures.
C. There is an area rug covering a tile floor. Area rugs are a significant tripping hazard, especially for older adults with osteoporosis, as a fall could lead to fractures. The nurse should intervene to recommend removing or securing the rug to reduce the risk of falls.
D. Prescriptions are stored in a medication organizer. A medication organizer helps older adults manage their medications effectively and reduces the risk of missed or incorrect doses.
A nurse is caring for a client who has severe rheumatoid arthritis in her hands and is unable to feed herself. For which of the following health care team members should the nurse request a referral from the provider?
A. Social worker
Social worker:While social workers play a crucial role in addressing various aspects of a patient's well-being, such as psychosocial needs and support systems, they may not be the primary healthcare team member to address the specific issue of a client with severe rheumatoid arthritis being unable to feed herself.
B. Physician assistant
Physician assistant:Physician assistants are medical professionals who work under the supervision of a physician. While they contribute to the overall care of the patient, they may not be the primary specialist for addressing the functional limitations and specific needs associated with severe rheumatoid arthritis.
C. Physical therapist
Physical therapist:Physical therapists primarily focus on physical rehabilitation, movement, and mobility. While they may be involved in the overall care plan for a patient with rheumatoid arthritis, the specific issue of hand function and activities of daily living, such as feeding, is more directly addressed by occupational therapists.
D. Occupational therapist
Occupational therapist:The correct choice. Occupational therapists specialize in helping individuals regain or improve their ability to perform daily activities, such as feeding, dressing, and grooming. In the case of severe rheumatoid arthritis affecting the hands, an occupational therapist can work with the client to develop strategies, adaptive equipment, and exercises to enhance hand function and promote independence in activities of daily living.
Full Explanation
A. Social worker:
While social workers play a crucial role in addressing various aspects of a patient's well-being, such as psychosocial needs and support systems, they may not be the primary healthcare team member to address the specific issue of a client with severe rheumatoid arthritis being unable to feed herself.
B. Physician assistant:
Physician assistants are medical professionals who work under the supervision of a physician. While they contribute to the overall care of the patient, they may not be the primary specialist for addressing the functional limitations and specific needs associated with severe rheumatoid arthritis.
C. Physical therapist:
Physical therapists primarily focus on physical rehabilitation, movement, and mobility. While they may be involved in the overall care plan for a patient with rheumatoid arthritis, the specific issue of hand function and activities of daily living, such as feeding, is more directly addressed by occupational therapists.
D. Occupational therapist:
The correct choice. Occupational therapists specialize in helping individuals regain or improve their ability to perform daily activities, such as feeding, dressing, and grooming. In the case of severe rheumatoid arthritis affecting the hands, an occupational therapist can work with the client to develop strategies, adaptive equipment, and exercises to enhance hand function and promote independence in activities of daily living.