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?

Drop the sterile gauze from 25.4 cm (10 in) above the sterile field.

Hold the sterile package in his dominant hand and open the top flap of the package toward his body.

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 A

Rationale:

A. Drop the sterile gauze from 25.4 cm (10 in) above the sterile field: Dropping sterile items from a height of about 6 to 12 inches prevents contamination by keeping hands outside the sterile field and ensuring the item lands safely without touching nonsterile surfaces.

B. 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 maintain sterility and prevent the arm from crossing over the sterile field, which would risk contamination.

C. Place objects 1.27 cm (0.5 in) inside the border of the sterile field: The outer 2.5 cm (1 inch) of the sterile field is considered contaminated. Placing items only 0.5 inches inside this border would place them within the contaminated zone, risking sterile field compromise.

D. Position the bottle outside the edge of the sterile field when pouring solution into a sterile container: While the bottle should not touch the sterile field, it must be close enough to pour without splashing, and the sterile container must be inside the sterile field.

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Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:

A. "I should take this medication on an empty stomach.": Amitriptyline does not require administration on an empty stomach. It can be taken with or without food, although taking it with food may help reduce gastrointestinal discomfort in some individuals.

B. "I can continue to take St. John's wort while taking this medication.": St. John's wort can increase the risk of serotonin syndrome and reduce the effectiveness of amitriptyline due to drug interactions. Clients should avoid combining herbal supplements with antidepressants.

C. "I know it will be a couple of weeks before the medication helps me feel better.": Tricyclic antidepressants like amitriptyline take 2 to 4 weeks to show noticeable improvement in mood. Recognizing the delayed onset helps set realistic expectations and supports adherence.

D. "I expect this medication to raise my blood pressure.": Amitriptyline more commonly causes orthostatic hypotension, especially when therapy is initiated. Clients should be taught to change positions slowly to reduce the risk of dizziness and falls.

A. Use a mechanical voice amplifier. B. Provide educational materials with large print. C. Have the client's glasses brought from home. D. Establish alternatives to verbal conversation.

Correct Answer is D

Explanation

Rationale:

A. Use a mechanical voice amplifier: A voice amplifier benefits clients with impaired vocal strength but does not help clients with expressive aphasia, who struggle to form or express language, not to project it audibly.

B. Provide educational materials with large print: Large print materials are helpful for clients with visual impairments but do not address language expression difficulties. Expressive aphasia requires alternative communication strategies, not visual aids.

C. Have the client's glasses brought from home: Glasses improve vision, not speech or language production. While helpful overall, they do not assist with the core issue of expressive aphasia, which is rooted in brain-language pathways.

D. Establish alternatives to verbal conversation: Using picture boards, writing tools, gestures, or communication apps helps clients express needs and ideas despite speech limitations. These strategies support more effective communication in expressive aphasia.

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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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