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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Cleanse the wound with cotton balls – Cotton fibers can shed and leave debris in the wound, increasing the risk of infection. Gauze or irrigation is preferred.
B. Use a 10-mL syringe filled with cleansing solution – A 10-mL syringe does not provide sufficient pressure for effective irrigation. A 30- to 60-mL syringe is typically recommended.
C. Hold the syringe tip 2.5 cm (1 in) above the upper end of the wound – This ensures appropriate pressure and prevents contamination while effectively flushing out debris.
D. Dry the wound bed with gauze squares – The wound bed should be kept moist to promote healing; only the surrounding skin should be dried if necessary.
Correct Answer is A
Explanation
Rationale:
A. Regular clinical breast examinations by a healthcare provider are recommended for all women, typically starting at age 30, regardless of family history, as part of early detection efforts for breast cancer.
B. While mammograms are important for breast cancer screening, the age at which they should start may vary based on individual risk factors and guidelines from different organizations.
C. Breast ultrasound may be used in specific cases but is not typically recommended as a routine screening tool for breast cancer in asymptomatic women without specific risk factors.
D. Breast self-examinations are important for women to become familiar with their breasts and detect any changes, but the age at which they should start may vary based on individual risk factors and guidelines.
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