The nurse admits a client to the physician's office who requires excision of a small mole on the forearm. The nurse establishes a sterile field, and places the needed equipment and supplies while maintaining sterility
After the tray is prepared, the nurse, while waiting for the physician to arrive: 1. Covers the tray with a sterile drape, and admits another client.
2. Tells the client not to touch anything on the tray, and notifies the doctor the client is ready.
3. Remains in the room.
4. Moves the sterile tray out into the hallway while admitting another client.
3
Rationale: Once the sterile field is established, it must be observed at all times, because contamination cannot be seen.
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A patient has been stabbed just below the left nipple. The nurse would assess for damage to which structures? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply
1. Lung 2. Heart 3. Spleen 4. Subclavian vein 5. Diaphragm
A health care provider prescribes feedings of 1 to 2 oz Pedialyte every 3 hours and to advance to 1/2 strength Similac with iron as tolerated postoperatively for an infant who had a pyloromyotomy
The nurse should decide to advance the feeding if which occurs? a. The infant's IV line has infiltrated. b. The infant has not voided since surgery. c. The infant's mother states the infant is tolerating the feeding okay. d. The infant is taking the Pedialyte without vomiting or distention.
A nurse is working with low-income disabled families who have young children. Which of the following considerations should be made by the nurse?
a. The children who are at greatest risk for abuse have physical disabilities. b. The children who are at greatest risk for abuse have developmental delays. c. The children who are at greatest risk for abuse have mental retardation. d. The children who are at greatest risk for abuse have cognitive disabilities.
Which of the following clients has the greatest risk for friction-induced skin breakdown?
1. A client who is obese and is frequently incontinent of both urine and feces 2. A client who insists she is comfortable only when positioned on her left side 3. A client who is cognitively impaired and comforts herself by wringing her hands 4. An immobile client who slides down in the recliner where he spends the morning hours