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. Monitor the IV site every 8 hours: In infants, IV sites should be assessed much more frequently, typically every 1–2 hours, due to their fragile veins and higher risk of infiltration or phlebitis. Monitoring every 8 hours is insufficient for safety.
B. Use gauze to cover the IV insertion site: Transparent dressings are preferred for infants because they allow continuous visualization of the IV site for signs of infiltration, phlebitis, or infection. Gauze obscures the site and may delay detection of complications.
C. Obtain a 24-gauge catheter: A 24-gauge catheter is appropriate for peripheral IV access in infants. It is small enough to fit delicate veins while allowing adequate fluid and medication administration safely.
D. Insert the catheter into the foot: Foot veins are generally avoided in infants due to higher risk of complications and limited accessibility. Preferred sites include veins on the hands, forearms, or scalp, which are safer and easier to monitor.
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"E"}
Explanation
Rationale for Correct Choices
• Pain medication: Fractures cause pain due to bone and soft tissue injury. Administering analgesics helps manage discomfort, improves cooperation with care, and facilitates movement and participation in activities as tolerated. Pain control also reduces stress responses that can interfere with healing.
• Limb immobilization: Nondisplaced midshaft fractures of the radius and ulna require immobilization using a cast or splint to maintain proper alignment, prevent further injury, and promote bone healing. Immobilization also supports neurovascular protection and decreases the risk of displacement.
Rationale for Incorrect Choices
• Skin traction: Skin traction is typically used for femur or lower limb fractures, not isolated forearm fractures, and is unnecessary for nondisplaced radius and ulna fractures.
• Antibiotics: The fracture is closed and nondisplaced, with no open wound or infection, so prophylactic antibiotics are not indicated.
• Surgical consultation: Surgery is usually reserved for displaced, unstable, or complex fractures. This nondisplaced fracture can be managed conservatively with immobilization.
• Bed rest: While rest is important, strict bed rest is unnecessary for upper extremity fractures. The child can perform limited activities while the arm is immobilized.
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