A nurse is caring for a client who requires a sterile dressing change. The nurse should recognize that the surgical field has been contaminated if which of the following actions occur?
A pair of sterile forceps is allowed to rest in a container of sterile water on the field.
The sterile solution is poured with the bottle held over the field.
Unnecessary sterile items are placed on the field.
The handle of a pair of sterile scissors is resting 5 cm (2 in) from the field's edge.
The Correct Answer is B
Rationale:
A. Allowing sterile forceps to rest in a container of sterile does not affect the sterility of the field.
B. Pouring sterile solution with the bottle held over the field is an inappropriate technique since it breaches the sterility of the field.
C. Placing unnecessary sterile items on the field is not ideal, but it does not indicate contamination of the surgical field.
D. The handle of a pair of sterile scissors resting 5 cm (2 in) from the field's edge does not indicate contamination of the surgical field. The scissors should be placed within easy reach of the nurse but should not touch non-sterile items.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Rapid chewing is not a manifestation of dysphagia.
B. Increased hunger is not a manifestation of dysphagia.
C. A garbled voice can be a manifestation of dysphagia, as it may indicate difficulty swallowing or speaking.
D. Sneezing is not a manifestation of dysphagia.
Correct Answer is C
Explanation
Rationale:
A. Hyperthermia may indicate a transfusion reaction, but dyspnea is a more immediate concern.
B. Urticaria may indicate a mild allergic reaction, but dyspnea is a more immediate concern.
C. Dyspnea is a sign of a possible transfusion reaction and should be reported immediately to the provider.
D. A headache may indicate a mild reaction to the blood transfusion, but dyspnea is a more immediate concern.
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