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A nurse is preparing a sterile field to perform a sterile dressing change. Which of the following interventions should the nurse use to maintain surgical aseptic technique?

Hold hands folded below the waist after donning sterile gloves

Pick up and pour solutions with the palm of the hand covering bottle labels

Keep sterile items within a 1.3 cm (0.5 in) border of the sterile drape

Maintain sterile objects within the line of vision

Answer and Explanation

The Correct Answer is D

Maintain sterile objects within the line of vision.

A. Hold hands folded below the waist after donning sterile gloves. This is incorrect because holding hands below the waist can contaminate the gloves with microorganisms from the floor or clothing.
B. Pick up and pour solutions with the palm of the hand covering bottle labels. This is incorrect because covering bottle labels can obscure important information such as expiration dates or ingredients.
C. Keep sterile items within a 1.3 cm (0.5 in) border of the sterile drape. This is incorrect because the border of the sterile drape is considered contaminated and any sterile item that touches it becomes contaminated as well.
D. Maintain sterile objects within the line of vision. This is correct because keeping an eye on sterile objects ensures that they are not accidentally touched by nonsterile items or persons.

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Correct Answer is A

Explanation

A is correct because facilitating an interdisciplinary conference at the new facility for the family can help address their concerns, provide information about the client's plan of care, and promote continuity of care.
B is incorrect because referring the client and family to a social worker for assistance and a follow-up meeting is not enough to address their immediate concerns and does not involve other members of the health care team.
C is incorrect because reassuring the client's family that the same provider will provide care at the new facility may not be true and does not address their specific concerns about the level of care.
D is incorrect because telling the family that the rehabilitation facility has an excellent client care record is not enough to address their specific concerns and may sound dismissive.

A. Restrict fresh flowers from the client's room B. Have visitors maintain a distance of 1.8 m (6 feet) from the client C. Wear a surgical mask when providing client care D. Assign the client to a private room with negative air pressure

Correct Answer is D

Explanation

Assign the client to a private room with negative air pressure.

Rationale:

A. Incorrect. Restricting fresh flowers from the client's room is not necessary for infection control purposes. However, some clients with pulmonary tuberculosis may have hypersensitivity reactions to certain plants or flowers, so the nurse should assess the client's allergies before allowing them in the room.
B. Incorrect. Maintaining a distance of 1.8 m (6 feet) from the client is not sufficient to prevent transmission of tuberculosis. Visitors should also wear a HEPA respirator and limit their contact time with the client.
C. Incorrect. A surgical mask is not adequate to protect the nurse from inhaling airborne droplet nuclei that contain Mycobacterium tuberculosis. The nurse should wear a high-efficiency particulate air (HEPA) respirator when providing client care.
D. Correct. Assigning the client to a private room with negative air pressure is the most effective way to prevent the spread of tuberculosis to other clients and staff members. The room should have at least six air exchanges per hour and an exhaust system that vents directly to the outside.

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A nurse is preparing a sterile field to perform a sterile dressing change. Which of the following interventions should the nurse use to maintain surgical aseptic technique?

Nursing Test Bank

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Correct Answer is D

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