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. Telling the client that it is safe to touch her ostomy may not address the client's concerns or fears.
B. Requesting that someone from the client's family participate in the care may not address the client's concerns or fears.
C. Asking the client to explain her feelings allows the nurse to understand the client's concerns or fears and address them appropriately.
D. Explaining why her participation is important may not address the client's concerns or fears.
Correct Answer is B
Explanation
Rationale:
A. Clamping the tube when going for a walk is not recommended because it can cause urine to back up into the bladder.
B. Keeping the drainage bag below the level of the waist is recommended to prevent reflux of urine and reduce the risk of infection.
C. Emptying the drainage bag once a day may not be frequent enough to prevent urinary stasis and infection.
D. Applying antiseptic ointment to the tip of the penis is not recommended because it can cause irritation and discomfort.
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