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 B
Explanation
Choice A reason: Removing a thermometer for use on another client risks cross-contamination, as C. difficile spores are highly transmissible. Dedicated equipment is required to prevent spread, so this action is incorrect and violates infection control protocols.
Choice B reason: Wearing a gown during care prevents C. difficile spore transmission via contact, a key precaution for this infection. This aligns with CDC contact isolation guidelines, protecting staff and other patients, making it the correct action.
Choice C reason: Washing hands with alcohol-based cleaner is ineffective against C. difficile spores, which require soap and water to physically remove them. This action is incorrect and inadequate for infection control in this scenario.
Choice D reason: Wearing an N95 respirator is unnecessary, as C. difficile is not airborne. Contact precautions (gown, gloves) suffice, so this action is incorrect and overprotective, wasting resources without addressing the transmission mode.
Correct Answer is B
Explanation
Choice A reason: Hypernatremia is unlikely with 0.45% sodium chloride, a hypotonic solution that dilutes serum sodium. Over-infusion risks hyponatremia, not high sodium levels. Monitoring for hypernatremia is inappropriate, as the solution’s low sodium content does not contribute to elevated sodium in fluid therapy.
Choice B reason: Assessing for fluid overload is essential, as 0.45% sodium chloride, being hypotonic, can cause water to shift into cells, risking pulmonary or cerebral edema. This is critical in clients with renal or cardiac issues, where monitoring for dyspnea or swelling ensures safe fluid administration.
Choice C reason: Hypoglycemia is not directly linked to 0.45% sodium chloride, which affects fluid and electrolytes, not glucose. Fluid shifts may indirectly stress metabolism, but hypoglycemia relates to fasting or insulin issues, making this an inappropriate focus for monitoring in this fluid therapy context.
Choice D reason: Dehydration is unlikely, as 0.45% sodium chloride provides free water, promoting hydration. It corrects hypernatremia or replaces fluid losses. Evaluating for dehydration is unnecessary unless infusion is inadequate or losses persist, which is not indicated in the context of this hypotonic solution.
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