when preparing a sterile field for a procedure which action should the nurse take to maintain sterility
Logo

Nursing Elites

HESI LPN

HESI PN Exit Exam

1. When preparing a sterile field for a procedure, which action should the nurse take to maintain sterility?

Correct answer: D

Rationale: To maintain sterility when preparing a sterile field, it is essential to avoid reaching over the sterile field. This action can introduce contaminants from the nurse's clothing or unsterile areas, compromising the sterility of the field. Placing sterile items around the sterile field (choice A) is incorrect as it may increase the risk of contamination by extending the area where non-sterile items may come in contact. Keeping hands below waist level (choice B) is also incorrect as it does not prevent contamination effectively. Opening the sterile package away from the body (choice C) is incorrect since it exposes the contents to the nurse's body, which is not sterile.

2. The nurse is teaching a client with diabetes mellitus how to differentiate between hypoglycemia and ketoacidosis. What statement indicates to the nurse that the client has an understanding of this condition?

Correct answer: D

Rationale: The correct answer is D. Shakiness is a symptom of hypoglycemia, which is low blood sugar. Taking glucose can help raise blood sugar levels quickly in this situation. Fruity breath odor and excessive urination are signs of ketoacidosis, a complication of diabetes involving high levels of ketones in the blood. Blurred vision can be a symptom of high blood sugar, but it is not specific to hypoglycemia.

3. At the end of a 12-hour shift, the PN observes the urine in a client's drainage bag as seen in the picture. Which action should the PN take next?

Correct answer: D

Rationale: Noting the white blood cell count is the most appropriate action in this situation. Changes in urine appearance could indicate infection, and assessing the white blood cell count helps in evaluating the possibility of infection. This is crucial for understanding the client's overall condition. The other options are not directly related to assessing infection based on urine appearance. Offering analgesics, checking glucose levels, or determining bladder distention may not address the underlying issue of a potential infection.

4. What is the function of the epiglottis during swallowing?

Correct answer: A

Rationale: The epiglottis is a flap of tissue that closes over the trachea during swallowing to prevent food and liquids from entering the airway. Choice A is correct because the primary function of the epiglottis is to act as a lid over the trachea, ensuring that food goes down the esophagus and not into the windpipe. Choices B, C, and D are incorrect as they do not describe the specific role of the epiglottis during swallowing.

5. The mother of a 9-month-old child diagnosed with respiratory syncytial virus (RSV) yesterday calls the clinic to inquire if it will be all right to take her infant to a friend's child's first birthday party the following day. Which response should the nurse provide?

Correct answer: A

Rationale: The correct response is A: 'Do not expose other children as the virus is very contagious even without direct contact.' RSV is highly contagious, especially in young children. Allowing the infected child to attend a birthday party can put other children at risk of contracting the virus. Choice B is incorrect as RSV can remain contagious for a period of time. Choice C is not sufficient, as wearing a mask may not entirely prevent the spread of the virus. Choice D is inaccurate, as children under 5 months are not the only ones susceptible to RSV; all young children are at risk.

Similar Questions

A client who had a left hemicolectomy is experiencing a low-grade fever on post-operative day three. What is the nurse's best action?
Which of the following is a primary intervention for a patient experiencing hypoglycemia?
What disorder closely matches Suzy's symptoms?
A client with a recent total knee replacement is scheduled for physical therapy. The client refuses to participate, stating that the pain is too intense. What should the nurse do first?
What is the first step in using an automated external defibrillator (AED) on a patient who has collapsed?

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses