A nurse is preparing a sterile field. Which of the following actions should the nurse identify as contaminating the field?

Holding a sterile item at just above waist level

Placing a sterile dressing 5 cm (2 in) from the border of the sterile field

Opening the sterile tray by first unfolding the flap farthest from his body

Opening a sterile package over the middle of the sterile field

Answer and Explanation

The Correct Answer is D

A reason:

Holding a sterile item at just above waist level is correct practice. This helps maintain the sterility of the item by keeping it within the sterile field and preventing it from touching non-sterile surfaces.

B reason:

Placing a sterile dressing 5 cm (2 in) from the border of the sterile field is appropriate. The edges of the sterile field (usually about 2.5 cm or 1 in) are considered non-sterile, so placing items within this boundary maintains sterility.

C reason:

Opening the sterile tray by first unfolding the flap farthest from the body is correct. This technique prevents the nurse's hands and arms from passing over the sterile contents, thus maintaining the sterility of the field.

D reason:

Opening a sterile package over the middle of the sterile field is incorrect. This action can lead to contamination as the outer packaging, which is non-sterile, could contact the sterile field.

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Correct Answer is B

Explanation

A reason:

Placing the wheelchair at a 90-degree angle to the bed is not the most effective position for transfer. A 45-degree angle is typically recommended to facilitate a smoother and safer transfer.

B reason:

Locking the wheels of the bed and the wheelchair is correct. This prevents any movement of the bed or wheelchair during the transfer, ensuring the safety of both the client and the nurse.

C reason:

Elevating the bed to a position of comfort for the nurse may be necessary, but the priority is to ensure the bed height is appropriate for a safe transfer, not just for the nurse's comfort.

D reason:

Acquiring the help of several people to lift the client is not always necessary. Using proper transfer techniques, equipment, and positioning can enable a single nurse to safely transfer a client, depending on the client's mobility and weight.

Correct Answer is ["740"]

Explanation

To convert the fluid intake to mL:

4 oz juice = 120 mL
6 oz tea = 180 mL
Ice chips melt to half their volume = 50 mL
IV bolus = 150 mL
8 oz broth = 240 mL

Adding these values gives: 120 + 180 + 50 + 150 + 240 = 740 mL

Therefore, the nurse should record a total intake of 740 mL.

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A nurse is preparing a sterile field. Which of the following actions should the nurse identify as contaminating the field?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is completing an 8-hour I&O record for a client who consumed 4 oz juice, 6 oz tea, a 100 mL cup full of ice chips, an IV bolus of 150 mL, and 8 oz broth. The nurse should record how many mL of intake on the client's record?

Correct Answer is ["740"]

Explanation

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