A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field?

Place the sterile dressing within 1.25 cm (0.5 in) of the edge of the sterile field.

Open the outermost flap of the sterile kit toward the body.

Place the cap from the solution sterile side up on a clean surface.

Set up the sterile field 5 cm (2 in) below waist level.

Answer and Explanation

The Correct Answer is C

A. Place the sterile dressing within 1.25 cm (0.5 in) of the edge of the sterile field: This action is not appropriate, as sterile items should be placed at least 2.5 cm (1 in) away from the edge of the sterile field to maintain sterility and prevent contamination.

B. Open the outermost flap of the sterile kit toward the body: The correct practice is to open the outermost flap away from the body. This technique helps prevent any contaminants from the nurse's clothing or body from falling into the sterile field.

C. Place the cap from the solution sterile side up on a clean surface: This is the correct action. By placing the cap sterile side up, the nurse minimizes the risk of contamination to the sterile solution and maintains the integrity of the sterile field.

D. Set up the sterile field 5 cm (2 in) below waist level: Setting up a sterile field below waist level increases the risk of contamination, as it may come into contact with non-sterile surfaces. The sterile field should be set up at waist level or higher to maintain sterility.

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Correct Answer is D

Explanation

A) "Raise the side rails up when the client is in bed.": While raising side rails may provide a sense of security, it can also increase the risk of falls if the client attempts to climb over them. Side rails should be used judiciously and are not always the safest option for clients with dementia.

B) "Place the bedside table at the foot of the bed.": This action can actually increase the risk of injury, as it makes it more difficult for the client to access necessary items, potentially leading to confusion and unsafe movements. Keeping essentials within easy reach can help prevent accidents.

C) "Keep the television on during the night.": While this may provide some comfort, it can also lead to confusion and disrupt sleep patterns for a client with dementia. A calm, quiet environment is generally more conducive to safety and well-being.

D) "Assist the client to the toilet frequently.": This is the most effective action to reduce the risk of injury. Regular assistance to the toilet helps prevent accidents and encourages toileting before the client feels an urgent need, which can lead to falls or confusion. Frequent checks can also help the client maintain dignity and comfort.

A. Ensure that the client's family supports the provider's decision for surgery. B. Determine if the client's health care surrogate is aware of the risks and benefits of the procedure. C. Send the unsigned informed consent farm to the facility's risk manager. D. Determine if the procedure is medically necessary for the client.

Correct Answer is B

Explanation

A) Ensuring that the client's family supports the provider's decision for surgery is important, but it is secondary to confirming that the healthcare surrogate is informed about the risks and benefits. The family’s emotional support is valuable, but informed consent is paramount.

B) Determining if the client's health care surrogate is aware of the risks and benefits of the procedure is crucial. Since the client is in a coma and unable to provide informed consent, the surrogate must be fully informed to make appropriate decisions regarding the client's care. This ensures that the rights and wishes of the client are upheld.

C) Sending the unsigned informed consent form to the facility's risk manager may be a procedural step in some situations, but it does not directly address the immediate need for informed consent or ensure that the healthcare surrogate understands the implications of the procedure. This action can be part of post-decision documentation but is not the first priority.

D) Determining if the procedure is medically necessary is important; however, the immediate concern is ensuring that informed consent is obtained from the health care surrogate. Understanding the necessity of the procedure can be part of the discussion with the surrogate but does not replace the need for informed consent.

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A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field?

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