A nurse is preparing a sterile field for a client who requires a dressing change. Which of the following actions should the nurse plan to take?
Hold the sterile package in his dominant hand and open the top flap of the package toward his body.
Drop the sterile gauze from 25.4 cm (10 in) above the sterile field.
Place objects 1.27 cm (0.5 in) inside the border of the sterile field.
Position the bottle outside the edge of the sterile field when pouring solution into a sterile container.
The Correct Answer is D
Rationale:
A. Hold the sterile package in his dominant hand and open the top flap of the package toward his body: The top flap should be opened away from the nurse’s body to avoid reaching over and contaminating the sterile field. Opening toward the body risks touching or dropping contaminants onto the field.
B. Drop the sterile gauze from 25.4 cm (10 in) above the sterile field: Sterile items should be dropped from a minimal height, close to the field, to prevent them from bouncing, falling off, or becoming contaminated. A 10-inch drop increases the risk of contamination.
C. Place objects 1.27 cm (0.5 in) inside the border of the sterile field: The outer 1 inch (2.5 cm) of a sterile field is considered contaminated, not just 0.5 inches. Placing objects inside only 0.5 in does not guarantee sterility and may result in contamination.
D. Position the bottle outside the edge of the sterile field when pouring solution into a sterile container: Keeping the bottle outside the sterile field prevents contamination from the outside of the bottle. Only the sterile contents should enter the sterile container, maintaining the integrity of the sterile field during the dressing change.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Having no vesicles prevents the spread of transmission: HSV-2 can be transmitted even when no visible lesions are present through asymptomatic viral shedding. The client should use barrier protection, such as condoms, during all sexual activity to reduce transmission.
B. Antibiotics are the primary treatment for this infection: HSV-2 is a viral infection, and antibiotics are ineffective against viruses. The mainstay of treatment involves antiviral medications such as acyclovir, valacyclovir, or famciclovir.
C. It is a latent infection that may reactivate periodically: HSV-2 remains dormant in nerve ganglia after the initial infection and can reactivate intermittently, leading to recurrent outbreaks triggered by stress, illness, or immunosuppression.
D. It is recommended any partners receive a vaccine to prevent this infection: There is currently no vaccine available to prevent HSV-2 infection. Prevention relies on consistent condom use, abstaining during outbreaks, and open communication with sexual partners about infection status.
Correct Answer is D
Explanation
Rationale:
A. "I understand that my scars will eventually fade.": This statement reflects acceptance and understanding of the healing process rather than distress about appearance. It indicates the client is cognitively processing changes without expressing body image disturbance.
B. "I am ready to join a breast cancer support group.": Willingness to participate in a support group demonstrates coping and adjustment. The client is seeking social and emotional support, which is a healthy response to surgery rather than a sign of altered body image.
C. "I want to have reconstructive surgery as soon as I can.": Desire for reconstructive surgery is a proactive coping strategy and a way to regain body image control. It reflects planning for recovery rather than expressing negative feelings about current body changes.
D. "I prefer to leave the lights off when I am changing my clothes.": Avoiding exposure of the body and seeking darkness when changing clothes indicates discomfort and distress with physical appearance. This behavior reflects an altered body image and difficulty accepting the changes after surgery.
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