A nurse is caring for a postoperative client and observes evisceration of the abdominal surgical wound. After covering the wound with a sterile, saline-soaked dressing, which of the following actions should the nurse take?

Choice A rationale:

Selecting an injection site on the abdomen 5 cm (2 in) from the umbilicus might be an appropriate instruction for some subcutaneous injections, but the specific injection site can vary based on the medication and client's needs. This choice is not a universal instruction for all subcutaneous injections.

Choice B rationale:

Expelling the air bubble from a prefilled syringe before injecting the medication is essential to ensure accurate dosing. Air bubbles can displace medication and lead to underdosing. This step is crucial for safe and effective administration.

Choice C rationale:

Aspirating prior to injecting medication is a technique used for intramuscular injections to ensure the needle is not in a blood vessel. However, for subcutaneous injections, aspirating is not necessary or recommended, as it can cause tissue damage and discomfort.

Choice D rationale:

Inserting the needle at a 15° angle is not a standard practice for subcutaneous injections. Subcutaneous injections are typically administered at a 45° or 90° angle, depending on the needle length and client's body composition. A 15° angle would not ensure proper medication delivery.

The correct answer is Choice A.

Choice A rationale: Placing a sterile kit on the overbed table above waist level maintains the sterility of the field. This position ensures that the kit is not contaminated by lower surfaces or inadvertent touch, which is essential for preventing infection during dressing changes.

Choice B rationale: Opening the outermost flap of the sterile kit toward their body increases the risk of contaminating the sterile field. The first flap should be opened away from the body to maintain the sterility of the field and prevent contamination.

Choice C rationale: Turning their back to the sterile field when coughing is incorrect because it increases the risk of contamination. The nurse should step away from the sterile field and cough into their elbow or use a mask to maintain sterility.

Choice D rationale: Holding a package of sterile gauze 30.5 cm (12 in) above the sterile field when dropping the gauze onto the field is too high and increases the risk of contamination. The gauze should be held closer, approximately 6 inches above the field, to ensure accuracy and sterility.