A charge nurse is observing a nurse perform a sterile dressing change for a client. Which of the following actions should the charge nurse identify as demonstrating sterile technique?
The nurse places the sterile package with the top flap opening away from the body.
The nurse pinches the flap on the inside of the package first to open it.
The nurse reaches over the package to open the left flap.
The nurse pulls the last flap of the package away from the body.
The Correct Answer is A
Choice A rationale:
Placing the sterile package with the top flap opening away from the body is the correct choice. This technique helps maintain the sterility of the contents by preventing potential contamination from the nurse's body and clothing.
Choice B rationale:
Pinching the flap on the inside of the package first to open it is not a recommended sterile technique. It could potentially introduce contamination from the nurse's hand into the sterile field when pinching the inner flap.
Choice C rationale:
Reaching over the package to open the left flap is not the ideal technique. Reaching over the sterile field can introduce the risk of contamination, as the nurse's arm and body might come into contact with the sterile supplies.
Choice D rationale:
Pulling the last flap of the package away from the body is not the most effective technique. This action could potentially lead to the nurse's hand coming close to or over the sterile field, increasing the risk of contamination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Child Protective Services would not be the appropriate agency to refer the guardian of the newborn who requires apnea monitoring at home. Child Protective Services deals with child abuse, neglect, and welfare concerns, which are not related to the specific medical needs of the newborn.
Choice B rationale:
Public Health is the correct choice. Public Health agencies are responsible for promoting and protecting the health of the community. They often provide services such as education, vaccinations, and resources for newborn care. Referring the guardian to Public Health can ensure that they receive appropriate guidance on how to manage the newborn's apnea monitoring needs at home and any other relevant health-related information.
Choice C rationale:
Home Health is not the most suitable agency in this context. Home Health agencies generally provide healthcare services directly in patients' homes, often for individuals who require medical assistance or supervision due to illnesses or post-surgical care. However, for a newborn requiring apnea monitoring, the focus is more on education and support rather than direct medical care.
Choice D rationale:
Women, Infants, and Children (WIC) is not the appropriate agency for referring the guardian of the newborn needing apnea monitoring. WIC is a program that provides supplemental nutrition and support to pregnant women, breastfeeding mothers, and young children. While it is important for the overall health of the newborn, it is not directly related to apnea monitoring or home care.
Correct Answer is C
Explanation
Answer is c. Receiving moderate sedation.
a. Removal of staples from a surgical wound: This procedure is typically considered routine and minimally invasive, involving the removal of staples used for wound closure. While it involves physical manipulation of the wound site, it does not carry significant risks or require the alteration of the patient's consciousness. Therefore, obtaining informed consent for this procedure is not typically necessary as it falls within the standard of care for post-operative wound management.
b. Providing a sputum specimen: Collecting a sputum specimen is a non-invasive procedure commonly performed to aid in the diagnosis of respiratory conditions such as infections or chronic lung diseases. It involves expectorating mucus from the respiratory tract, which does not pose significant risks to the patient. As such, informed consent is usually not required for this procedure since it is relatively simple and does not involve any invasive interventions or alteration of consciousness.
c. Receiving moderate sedation: Correct. Moderate sedation involves the administration of drugs, typically benzodiazepines or opioids, to induce a state of decreased consciousness and relaxation while maintaining the patient's ability to respond to verbal commands and physical stimulation. This procedure carries inherent risks, including respiratory depression, cardiovascular complications, and potential allergic reactions to the medications used. Due to the potential for adverse effects and the altered state of consciousness induced by moderate sedation, informed consent is necessary to ensure that patients understand the risks and benefits of the procedure before it is performed.
d. Collection of a blood specimen for ABGs: Arterial blood gas (ABG) analysis involves the collection of a blood sample from an artery, typically the radial artery in the wrist, to assess the patient's acid-base balance, oxygenation status, and ventilation. While this procedure does involve puncturing the skin and accessing the arterial blood supply, it is considered a standard diagnostic test in many clinical settings. However, the invasiveness of the procedure and potential risks such as bleeding, hematoma formation, and arterial injury may necessitate informed consent in certain situations, especially if the patient has underlying coagulopathies or other risk factors that could increase the likelihood of complications.
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