a nurse is preparing to perform a sterile dressing change for a client which of the following actions should the nurse plan to take
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Nursing Elites

HESI LPN

HESI Fundamentals 2023 Quizlet

1. A healthcare professional is preparing to perform a sterile dressing change for a client. Which of the following actions should the healthcare professional plan to take?

Correct answer: B

Rationale: Setting up the sterile field at waist level is crucial to maintaining its sterility during a dressing change. Choice A is incorrect because sterile gloves should be worn after opening sterile dressing supplies to prevent contamination. Choice C is incorrect as the entire border of the sterile field should be considered contaminated to maintain sterility. Choice D is incorrect because the cap of a sterile solution should never be placed inside the sterile field to prevent contamination.

2. A nurse prepares an injection of morphine to administer to a client who reports pain but asks a second nurse to give the injection because another assigned client needs to use a bedpan. Which of the following actions should the second nurse take?

Correct answer: C

Rationale: The second nurse should prepare a new syringe and administer the medication to ensure proper and timely pain management. Administering another nurse's medication without preparation could lead to errors. Choice A is not the priority as the medication administration should take precedence. Choice B is not recommended as the second nurse should not administer medication prepared by another nurse. Choice D is inappropriate as patient needs should not be compromised for medication administration to another client.

3. A client with chronic obstructive pulmonary disease (COPD) is being discharged with home oxygen therapy. Which statement by the client indicates a need for further teaching?

Correct answer: B

Rationale: The correct answer is B. Petroleum jelly is flammable and should not be used with oxygen therapy due to the risk of fire. The client should avoid using petroleum-based products around oxygen equipment. Choices A, C, and D are all appropriate statements for a client with COPD receiving home oxygen therapy. Keeping the oxygen tank upright ensures proper oxygen flow, avoiding smoking or exposure to smoke helps prevent respiratory aggravation, and knowing to seek medical help promptly for breathing difficulties is essential for managing COPD effectively.

4. A nurse is preparing to administer methylprednisolone 10 mg by IV bolus. The amount available is methylprednisolone injection 40-mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Do not use a trailing zero.)

Correct answer: A

Rationale: To calculate the mL to administer, use the formula: Dose required (mg) ÷ Stock concentration (mg/mL) = Volume to administer (mL). In this case, 10 mg ÷ 40 mg/mL = 0.25 mL. However, when rounding to the nearest tenth, the answer should be 0.3 mL. Therefore, the nurse should administer 0.3 mL. Choice A is the correct answer. Choice B (0.25 mL) is the result obtained before rounding. Choice C (0.4 mL) and Choice D (0.5 mL) are incorrect calculations.

5. A client has right-sided paralysis following a cerebrovascular accident. Which of the following prescriptions should the nurse anticipate to prevent a plantar flexion contracture of the affected extremity?

Correct answer: A

Rationale: An ankle-foot orthotic is the correct choice to prevent a plantar flexion contracture in a paralyzed limb. An ankle-foot orthotic helps maintain proper alignment of the foot and ankle, preventing the foot from being permanently fixed in a pointed-down position. Continuous passive motion machines are typically used to promote joint movement after surgery and would not address the prevention of contractures in this case. Abduction splints are used to keep the legs apart and would not address the specific issue described. Sequential compression devices are used to prevent deep vein thrombosis by promoting circulation in the lower extremities and are not indicated for preventing plantar flexion contractures.

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