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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Applying lidocaine gel to the urethra may provide additional lubrication but does not address the immediate issue of resistance during catheter insertion.

B. Inflating the catheter's balloon is inappropriate at this stage, as the catheter is not properly positioned for urine flow, and doing so could cause injury.

C. Lowering the penis to a 45° angle helps to straighten the urethra and can facilitate easier passage of the catheter, making it the most appropriate action.

D. Twisting the catheter gently is not recommended, as this may cause trauma to the urethra or increase discomfort without resolving the resistance issue.

A. Photograph B. Medical diagnosis C. Room number D. Age

Correct Answer is A

Explanation

Rationale:

A. A photograph is a unique identifier that helps ensure the correct client receives the correct medications.

B. A medical diagnosis is not a unique identifier and may not be accurate if the client has multiple diagnoses.

C. A room number is not a unique identifier and may not be accurate if the client has been moved to a different room.

D. Age is not a unique identifier and may not be accurate if the client has multiple ages.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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