A nurse is preparing a sterile field for a client who requires a sterile procedure. Which of the following actions should the nurse plan to take?

Open the sterile drape by touching the inner surface first.

Place sterile items within a 1-inch border of the drape.

Hold sterile instruments above the waist and away from the body.

Pour sterile solution directly from a container held 12 inches above.

Answer and Explanation

The Correct Answer is C

Choice A reason: Touching the inner surface of a sterile drape first contaminates it, as only sterile gloves should contact this area. Outer edges are handled to maintain sterility, so this action violates sterile technique, making it incorrect.
Choice B reason: Placing items within a 1-inch border of the drape is incorrect, as this border is considered non-sterile. Sterile items must be placed centrally to avoid contamination, so this action breaches sterile field principles, making it incorrect.
Choice C reason: Holding sterile instruments above the waist and away from the body maintains sterility, as areas below the waist or close to the body are considered contaminated. This aligns with aseptic technique, making it the correct action for sterile field preparation.
Choice D reason: Pouring solution from 12 inches above risks splashing, contaminating the sterile field. Solutions should be poured from 4-6 inches to control flow and maintain sterility, so this action is incorrect and unsafe for sterile procedures.

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Correct Answer is C

Explanation

Choice A reason: Checking patency every 8 hours is inadequate for closed wound drainage systems, which require more frequent monitoring (e.g., every 4 hours) to detect blockages. Delayed checks risk fluid buildup, increasing infection or seroma risk, critical in postoperative wound management.
Choice B reason: Emptying the drainage system every 24 hours may be insufficient, as frequency depends on volume. Systems like Jackson-Pratt drains need emptying when half-full to maintain suction, preventing complications like infection, requiring flexible, volume-based schedules rather than fixed intervals.
Choice C reason: Securing the drainage system to the gown prevents dislodgement, maintaining suction and reducing infection risk. It supports mobility while stabilizing the system, preventing wound tension. This is critical for effective drainage and healing in postoperative clients with closed systems.
Choice D reason: Replacing the drainage system every 3 days is unnecessary unless infection or malfunction occurs. Routine replacement risks introducing pathogens or disrupting healing. Systems remain until drainage decreases, guided by clinical assessment, not a fixed schedule, to ensure safety.

A. Measure the client's apical pulse while another nurse measures their radial pulse. B. Compare the client's carotid pulse while resting to their carotid pulse after standing for 1 minute. C. After inflation, deflate a blood pressure cuff on the client's arm while palpating their brachial pulse. D. Assess both of the client’s radial pulses at the same time and compare the quality of pulsations.

Correct Answer is A

Explanation

Choice A reason: Measuring the apical pulse (at the heart) simultaneously with the radial pulse (at the wrist) by two nurses accurately detects a pulse deficit, which occurs when heartbeats do not translate to peripheral pulses, often in arrhythmias like atrial fibrillation. This method quantifies the difference, aiding diagnosis and treatment, making it the correct approach.
Choice B reason: Comparing carotid pulses at rest and after standing assesses orthostatic changes, not a pulse deficit. A pulse deficit reflects a discrepancy between central and peripheral pulses, not positional changes. This action is irrelevant to detecting pulse deficits, as it does not compare simultaneous heart and peripheral pulse rates.
Choice C reason: Deflating a blood pressure cuff while palpating the brachial pulse is used to measure blood pressure, not to assess a pulse deficit. This method does not compare central and peripheral pulses simultaneously, which is necessary to identify a deficit, making it an incorrect approach for this assessment.
Choice D reason: Assessing both radial pulses simultaneously evaluates symmetry but not a pulse deficit, which requires comparing the apical (heart) pulse with a peripheral pulse. This method misses the central-peripheral comparison critical for detecting discrepancies caused by arrhythmias, making it inadequate for assessing a pulse deficit.

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A nurse is preparing a sterile field for a client who requires a sterile procedure. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a closed wound drainage system. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is C

Explanation

A nurse is preparing to assess a client for a pulse deficit. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

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