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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
A) Palpable fontanels:By the age of 2, the anterior fontanel (soft spot on the top of the head) should have closed. Palpable fontanels are not expected in a 2-year-old toddler and could indicate a developmental issue.
B) Head circumference exceeds chest circumference:In a 2-year-old, the head circumference typically equals or is slightly less than the chest circumference. This finding is more common in infants rather than toddlers.
C) Natural loss of deciduous teeth:The natural loss of deciduous (baby) teeth usually begins around the age of 6 years. It is not expected in a 2-year-old toddler.
D) Nontender, protruding abdomen:A nontender, protruding abdomen is a normal finding in toddlers due to their developing musculature and posture. This is a common and expected characteristic in children of this age group.
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