what action should the nurse implement when adding sterile liquids to a sterile field
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Nursing Elites

HESI RN

HESI Fundamentals

1. What action should be taken when adding sterile liquids to a sterile field?

Correct answer: B

Rationale: If a sterile field becomes wet or damp during a procedure, it is considered contaminated as moisture can allow organisms to wick from the surface and compromise the sterility of the field. It is essential to maintain the integrity of the sterile field to prevent infections and ensure patient safety.

2. An older adult male client is admitted to the medical unit following a fall at home. When undressing him, the nurse notes that he is wearing an adult diaper, and skin breakdown is obvious over his sacral area. What action should the nurse implement first?

Correct answer: D

Rationale: The initial step the nurse should take when faced with skin breakdown over the sacral area of the client is to determine the size and depth of the affected area. Assessing and documenting these aspects are crucial before initiating any treatment. This evaluation will guide the nurse in developing an appropriate care plan to address the skin breakdown effectively. Options A, B, and C are not the first steps to take in this situation. While establishing a toileting schedule and completing a functional assessment are important, assessing the size and depth of the skin breakdown is the priority to initiate proper treatment. Applying a barrier ointment without assessing the extent of the breakdown may not address the underlying issue effectively.

3. The nurse determines that a postoperative client's respiratory rate has increased from 18 to 24 breaths/min. Based on this assessment finding, which intervention is most important for the nurse to implement?

Correct answer: D

Rationale: An increased respiratory rate can be a sign of various issues postoperatively, including pain. Assessing and managing pain is crucial as it can lead to tachypnea. Pain, anxiety, and fluid accumulation in the lungs can all contribute to an increased respiratory rate. Therefore, determining if pain is causing the tachypnea is the most important intervention to address the underlying cause. Encouraging ambulation, offering snacks, or forcing fluids are not the priority in this situation as pain assessment takes precedence in managing the increased respiratory rate.

4. The daughter of an older woman who became depressed following the death of her husband asks, 'My mother was always well-adjusted until my father died. Will she tend to be sick from now on?' Which response is best for the nurse to provide?

Correct answer: B

Rationale: The successful resolution of a developmental crisis in the later years involves acceptance and adaptation, and the daughter should be reassured that recovery is likely.

5. A client who has been on bed rest for several days is at risk for developing deep vein thrombosis (DVT). Which intervention should the nurse include in the client's plan of care?

Correct answer: B

Rationale: Applying antiembolism stockings as prescribed (B) is an effective intervention to prevent deep vein thrombosis (DVT) in a client on bed rest. While encouraging ambulation (A), elevating the legs (C), and performing passive range-of-motion exercises (D) are also beneficial, compression stockings are particularly effective in reducing the risk of DVT by promoting venous return and reducing stasis in the lower extremities.

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