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.

Answer and Explanation

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.

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Correct Answer is ["A","B","E"]

Explanation

Rationale:
A. Maintain the head of the bed at a 30 degree angle: Elevating the head of the bed promotes venous drainage from the brain and helps lower intracranial pressure (ICP). A 30-degree position optimizes cerebral perfusion without compromising blood flow to the brain tissue.

B. Administer stool softeners to the client: Stool softeners prevent straining during bowel movements, which increases intrathoracic and intracranial pressure. Preventing Valsalva maneuvers helps maintain stable ICP and reduces the risk of secondary brain injury.

C. Encourage the client to cough and deep breathe: Coughing can sharply increase ICP due to the rise in intrathoracic pressure. Clients with elevated ICP should be discouraged from coughing or performing any action that increases pressure in the head.

D. Obtain client vital signs every 8 hr: Clients with increased ICP require frequent monitoring, typically every 1 to 2 hours or continuously, depending on severity. Monitoring only every 8 hours is inadequate and could delay detection of critical changes in neurological status.

E. Provide a quiet environment for the client: Reducing environmental stimuli, such as noise and bright lights, prevents agitation and minimizes fluctuations in ICP. A calm and quiet setting supports cerebral stability and promotes healing.

A. A client who is receiving a blood transfusion and reports low-back pain B. A female client who is scheduled for chemotherapy and has an RBC count of 4.0 x105/uL (4.2 to 5.4 x106/uL) C. A client who is 24 hr postoperative following a transurethral resection of the prostate and has small blood clots in the drainage tubing D. A client who is 2 days postoperative following placement of an ascending colostomy and has shreds of bloody mucus in the bag

Correct Answer is A

Explanation

Rationale:
A. A client who is receiving a blood transfusion and reports low-back pain: Low-back pain during a blood transfusion indicates a possible acute hemolytic reaction caused by ABO incompatibility. This is a life-threatening emergency that requires immediate discontinuation of the transfusion and notifying the provider to prevent renal failure and shock.

B. A female client who is scheduled for chemotherapy and has an RBC count of 4.0 x10⁶/µL (4.2–5.4 x10⁶/µL): Although the RBC count is slightly low, this finding is not immediately life-threatening. The provider should be informed, but the client does not require urgent intervention.

C. A client who is 24 hr postoperative following a transurethral resection of the prostate and has small blood clots in the drainage tubing: Small clots are expected during the first 24 to 36 hours post-TURP due to residual bleeding from the surgical site.

D. A client who is 2 days postoperative following placement of an ascending colostomy and has shreds of bloody mucus in the bag: Small amounts of bloody mucus are normal during the early postoperative phase as the bowel mucosa heals.

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