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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Red meat is high in saturated fats and sodium, which can elevate blood pressure, worsening hypertension. It is not recommended for a heart-healthy diet, as it increases cardiovascular strain. The nurse should suggest leaner proteins instead, making this an incorrect dietary choice.
Choice B reason: Cheese is often high in sodium and saturated fat, contributing to increased blood pressure and cardiovascular risk in hypertension. Low-sodium alternatives are preferred, but cheese is generally discouraged, making this an inappropriate food to recommend for this client’s diet.
Choice C reason: Canned black beans are high in sodium, which exacerbates hypertension by promoting fluid retention and vascular strain. Rinsing reduces sodium, but fresh or low-sodium options are better. This choice is less ideal than fresh produce, making it incorrect for hypertension management.
Choice D reason: Fresh spinach is rich in potassium, magnesium, and fiber, which help lower blood pressure by counteracting sodium and relaxing blood vessels. It aligns with the DASH diet, an evidence-based approach for hypertension, making it the best food to recommend for this client’s condition.
Correct Answer is B
Explanation
Choice A reason: Taking diuretics with the evening meal increases nighttime urination, worsening urge incontinence by stimulating bladder activity during sleep. Diuretics should be taken earlier (e.g., morning) to align with daytime voiding schedules, reducing urgency episodes. This instruction is counterproductive for bladder retraining, making it inappropriate.
Choice B reason: Planning to urinate every 3 hours while awake establishes a scheduled voiding regimen, a key component of bladder retraining. This helps condition the bladder to delay urgency, reducing involuntary contractions and improving control. It aligns with evidence-based strategies for managing urge incontinence, making it the correct instruction.
Choice C reason: Limiting fluid intake to 1 liter per day risks dehydration and concentrated urine, which can irritate the bladder and worsen urge incontinence. Adequate hydration (2-3 L/day) supports bladder health and retraining by maintaining normal urine volume, making this instruction harmful and incorrect.
Choice D reason: Performing Kegel exercises once daily is insufficient for effective bladder retraining. Multiple daily sets (e.g., 3-4 times) strengthen pelvic floor muscles, improving bladder control. This frequency is too low to achieve therapeutic benefits for urge incontinence, making it less effective than scheduled voiding.
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