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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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"B"}}

Explanation

Rationale:

• Platelet count: A drop in platelet count occurs in both preeclampsia and HELLP syndrome because of vascular endothelial damage leading to platelet aggregation and consumption. In HELLP, thrombocytopenia is often more severe, typically <100,000/mm³.

• Alanine aminotransferase (ALT): Elevated ALT reflects hepatocellular injury. It is a hallmark of HELLP syndrome (the “EL” = Elevated Liver enzymes) due to hepatic ischemia and microvascular damage, whereas in preeclampsia it may remain normal or only mildly elevated.

• Blood pressure: Hypertension (≥140/90 mm Hg) is the defining feature of preeclampsia and is also commonly seen in HELLP syndrome, which usually evolves from severe preeclampsia.

• Hemoglobin: Hemolysis (“H” in HELLP) results in decreased hemoglobin levels. In preeclampsia, hemoglobin levels are typically normal unless there is concurrent hemoconcentration or progression to HELLP syndrome.

A. Obtaining the initial assessment of assigned clients B. Educating a client and family members on home care C. Changing a nonsterile dressing D. Interpreting a client's diagnostic laboratory results

Correct Answer is C

Explanation

Rationale:
A. Obtaining the initial assessment of assigned clients: The initial assessment requires nursing judgment and clinical decision-making, which are within the scope of practice of a registered nurse only. It involves data interpretation and establishing a baseline for care, tasks that cannot be delegated to assistive personnel.

B. Educating a client and family members on home care: Client and family teaching requires specialized nursing knowledge to ensure understanding and accuracy. This task involves evaluating learning needs and reinforcing critical information, responsibilities that cannot be legally delegated to assistive personnel.

C. Changing a nonsterile dressing: Assistive personnel can safely perform nonsterile procedures such as changing a clean dressing under the supervision of a nurse. This task involves routine care that does not require nursing judgment, making it appropriate for delegation.

D. Interpreting a client's diagnostic laboratory results: Interpretation of laboratory data involves analysis, clinical reasoning, and the ability to make informed nursing decisions. These actions fall strictly within the nurse’s professional scope of practice and cannot be delegated to assistive personnel.

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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

Naxlex Comprehensive Predictor Exams

The nurse is continuing to care for the client. Exhibits The nurse is reviewing the assessment findings. For each assessment finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process.

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"B"}}

Explanation

A nurse is making assignments for staff on an inpatient unit. Which of the following tasks can a nurse legally delegate to assistive personnel?

Correct Answer is C

Explanation

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