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 A
Explanation
Rationale:
A. "You can obtain a personal response system that will be activated if you fall.": A personal emergency response system allows the client to summon help immediately after a fall, promoting independence and safety for individuals living alone.
B. "You should contact a family member once a week to keep in touch.": Weekly contact provides emotional support but does not ensure timely assistance in the event of a fall. Regular communication is helpful, yet it does not directly reduce fall risk or guarantee safety if an emergency occurs.
C. "You can have an unlicensed assistive personnel (UAP) come to your house daily to stay with you.": Having a UAP visit daily may not be realistic or necessary, especially for independent seniors. This does not provide continuous supervision or an immediate response in case of a fall occurring outside scheduled visits.
D. "You need to move to a skilled nursing facility where they can prevent falls.": Suggesting relocation is premature and disregards the client’s desire for independence. Fall prevention strategies and assistive technology should be explored before recommending institutional care.
Correct Answer is D
Explanation
Rationale:
A. "Add salt to season foods.": Adding salt can irritate oral mucosa, especially in clients with AIDS who often develop stomatitis or oral candidiasis. Salty foods worsen pain and delay healing of mucosal lesions, so mild, bland foods are preferred.
B. "Eat foods served at hot temperatures.": Hot foods increase discomfort and can further damage already inflamed oral tissues. Clients should instead consume cool or room-temperature foods to soothe irritation and promote better oral intake.
C. "Rinse your mouth with an alcohol-based mouthwash.": Alcohol-based mouthwashes dry and irritate the mucous membranes, worsening oral pain and increasing the risk of bleeding or infection. Nonalcoholic rinses, such as saline or baking soda solutions, are safer alternatives.
D. "Use ice chips to numb your mouth.": Sucking on ice chips provides local numbing and temporary pain relief, allowing the client to eat and drink more comfortably. This simple intervention also helps keep the oral mucosa moist and reduces inflammation.
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