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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Correct Answer is D

Explanation

Rationale:

A. "Every so often, I think about whether or not to have this surgery.": This statement suggests the client is still ambivalent or uncertain, which means informed consent has not yet been fully achieved. Clients must be sure and fully informed before agreeing to proceed.

B. "I will talk with the doctor about my surgery when I get into the operating room.": Informed consent must be obtained well before the procedure begins. Waiting until the operating room is inappropriate, as the client may be under stress or sedation.

C. "Can you tell me more about the surgery I am having?": This indicates the client lacks essential information about the procedure. Informed consent requires that the client already understand the nature, risks, benefits, and alternatives before signing.

D. "Signing this form indicates that I give my permission for the surgery, right?": This reflects an understanding that the consent form gives legal authorization for the procedure. It shows the client knows their signature confirms informed agreement to the surgery.

Correct Answer is []

Explanation

Rationale for Correct Choices

Heart failure: The client’s symptoms bilateral crackles, +3 lower extremity edema, cool limbs with weak pulses, an S3 heart sound, and elevated BNP are classic signs of decompensated heart failure with volume overload and poor perfusion.
Educate the client about sodium restriction: Sodium contributes to fluid retention and increased cardiac workload. Dietary sodium restriction is crucial in preventing fluid overload, thus reducing exacerbations of heart failure symptoms such as edema and dyspnea.
Obtain a prescription for a diuretic: Diuretics like furosemide relieve volume overload by promoting fluid excretion. They help decrease pulmonary congestion, improve oxygenation, and reduce peripheral edema in heart failure patients.
Daily weight: Monitoring weight helps detect subtle changes in fluid balance. A sudden weight gain of 2–3 pounds in 24 hours may signal worsening heart failure and the need for diuretic adjustment.
Blood pressure: Blood pressure monitoring provides insight into cardiac output and guides medication titration. Both hypertension and hypotension can worsen outcomes in clients with heart failure.

Rationale for Incorrect Choices

Endocarditis: This condition presents with fever, new or changing murmurs, petechiae, or positive blood cultures. The absence of infection signs and the presence of systemic fluid overload point away from endocarditis.
Aortic stenosis: Typical signs include exertional dyspnea, syncope, chest pain, and a harsh systolic murmur not crackles, edema, or elevated BNP. This client’s profile better matches heart failure.
Mitral stenosis: This condition may cause pulmonary congestion but often presents with a diastolic murmur and atrial fibrillation, which are not described here.
Administer antibiotics as prescribed: Without clinical or laboratory signs of infection (fever, leukocytosis, or positive cultures), antibiotics are not appropriate for heart failure.
Prepare the client for cardioversion: Cardioversion is used for arrhythmias like atrial fibrillation with rapid ventricular response. The client has a normal apical pulse and no dysrhythmia signs.
Educate the client about valve replacement: Valve surgery is not indicated unless diagnostic findings confirm severe valvular disease. No murmur or echo data is provided here.
Skin lesions: These are associated with endocarditis, not heart failure. Findings like Janeway lesions or Osler nodes are not reported in this case.
Blood cultures: Indicated when bacteremia or endocarditis is suspected. Heart failure without infection signs does not warrant blood cultures.
Fever: The client is afebrile, making infection less likely. Fever is not a feature of uncomplicated heart failure and does not need monitoring here.

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