A nurse is observing a newly licensed nurse prepare a sterile field. For which of the following actions should the nurse intervene?
Positions the wrapped package on the bedside table so the outer flap is away from her.
Holds gauze packages 15 cm (6 in) above the sterile field.
Holds a bottle of solution with the label away from the palm of the hand.
Wears sterile gloves when moving sterile items on the sterile field.
The Correct Answer is C
A. Positions the wrapped package on the bedside table so the outer flap is away from her: This action is correct because opening the flap away from the body minimizes the risk of contaminating the sterile field.
B. Holds gauze packages 15 cm (6 in) above the sterile field: This action is correct. Dropping sterile items from a height of 6 inches or more prevents contamination by ensuring they do not touch the edges or outside surfaces of the sterile field.
C. Holds a bottle of solution with the label away from the palm of the hand: When pouring a solution, the label should be held toward the palm of the hand to protect it from damage caused by spills. A damaged label could make it difficult to identify the solution, increasing the risk of error.
D. Wears sterile gloves when moving sterile items on the sterile field: This action is appropriate. Sterile gloves help maintain the sterility of the field and are required when manipulating sterile items.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A client being discharged to a long-term care facility may need comprehensive discharge planning, which involves familiarity with long-term care requirements, but this is not typically within the primary expertise of a PACU nurse.
B. A client who is postoperative following a lobectomy and has a chest tube falls within the PACU nurse's area of expertise. PACU nurses are experienced in monitoring and managing postoperative clients, including those with chest tubes, as these clients require close monitoring for complications such as respiratory distress or chest tube malfunction.
C. Teaching about insulin self-administration is important, but this task is more suited to nurses experienced in chronic care management, such as those from medical-surgical or endocrinology units.
D. Teaching prior to initiating cardiac rehabilitation requires specialized knowledge in cardiac care, which may not be the primary focus of a PACU nurse's practice.
Correct Answer is A
Explanation
A. A PT of 45 seconds is prolonged and indicates a potential risk of bleeding due to excessive anticoagulation with warfarin. The nurse should notify the provider for further evaluation and adjustment of the warfarin dosage.
B. Platelets within the normal range (150,000-400,000/mm3) are adequate and do not require immediate provider notification.
C. Hematocrit of 44% is within the normal range for adults and does not indicate an urgent need for provider notification.
D. Hemoglobin of 16 g/dL is within the normal range for adults and does not require immediate provider notification.
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