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

Explanation

Rationale:
A. INR: The International Normalized Ratio (INR) is used to monitor the effectiveness and safety of warfarin therapy. It standardizes prothrombin time results, allowing clinicians to determine whether the client’s anticoagulation is within the therapeutic range to prevent clotting without causing excessive bleeding.

B. Factor VIII: Factor VIII is a clotting factor assessed in hemophilia or other coagulation disorders. It is not used to monitor warfarin therapy and does not indicate the therapeutic effect of anticoagulation.

C. Bleeding time: Bleeding time measures platelet function and vascular integrity, but it does not assess the anticoagulant effect of warfarin. It is unrelated to monitoring warfarin dosing.

D. aPTT: Activated partial thromboplastin time (aPTT) is used to monitor heparin therapy, not warfarin. It does not provide information about the client’s warfarin anticoagulation status.

A. 28 B. 23 C. 32 D. 42

Correct Answer is B

Explanation

Calculation:

Identify the client's weight in kilograms (kg) and height in meters (m).

Weight = 75 kg

Height = 1.8 m

Calculate the square of the height in meters (m squared).

Height squared = 1.8 m x 1.8 m

= 3.24 m squared.

Calculate the BMI.

BMI = Weight (kg) / Height (m squared)

= 75 kg / 3.24 m squared

= 23.148

Round the answer to the nearest tenth.

= 23.1

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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?

Nursing Test Bank

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