The nurse sets up a sterile field and notes several tiny holes in the sterile drape of the table that served as the wrap for the pack. What does the nurse do to facilitate completion of the proce-dure?
a. Uses a sterile towel to cover the existing holes
b. Replaces the entire sterile field and the supplies
c. Moves the sterile supplies to a replacement drape
d. Avoids using any of the sterile items near the holes
B
The nurse removes the entire sterile field, including any supplies added to the setup, because the holes compromised the sterility of the pack and its contents; in addition, contacting the contami-nated drape contaminates every sterile item added to the sterile field. Even if the contents of the pack remained sterile, once the drape was used as a sterile field, the field was contaminated by the holes. The nurse cannot proceed with a sterile procedure using a contaminated field despite the goal of facilitating the procedure. Ignoring the potential contamination increases the risk of infection.
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Which of the following describes the process of identifying a nursing diagnosis?
a. Selecting a nursing diagnosis from a list approved by the North American Nursing Diagnosis Association (NANDA) b. Identifying the patient's strengths and weaknesses c. Setting goals for nursing care d. Reviewing medical-surgical nursing texts for patterns of disease processes
While assessing a group of patients, the nurse recognizes the patient who could qualify for Medicaid benefits is the:
a. 35-year-old unemployed single mother with diabetes. b. 70-year-old Medicare recipient with re-tirement income who needs to be in a long-term care facility. c. 80-year-old blind woman living in her own home who has inadequate private insurance. d. 67-year-old stroke victim with Medicare Part A and an income from investments.
Clients with kidney stones are usually advised to:
1. Avoid organ meats 2. Drink 3 liters of fluid per day 3. Take 8 ounces of cranberry juice daily 4. Eliminate calcium-containing foods from their diet
Evidence suggests that enteral nutrition (EN) is superior to parenteral nutrition (PN) and will impact client mortality among the critically ill in the ICU. Early EN has been noted to which of the following? Select all that apply
A) Lessen disease severity B) Modulate inflammatory responses C) Maintain the integrity of the gastrointestinal mucosa D) Prevent an ileus E) Prevent weight loss