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) Kaposi's sarcoma lesions: Kaposi's sarcoma is a cancer that commonly appears in individuals with immunocompromised states, such as those with HIV/AIDS. It is not associated with systemic lupus erythematosus (SLE). Therefore, finding Kaposi's sarcoma lesions would not be expected in a client with SLE.

B) Hemangiomas: Hemangiomas are benign vascular tumors typically seen in infants and children. While they can occur in various skin conditions, they are not characteristic of systemic lupus erythematosus. Thus, finding hemangiomas would not be relevant in this context.

C) Psoriasis: Psoriasis is a chronic autoimmune condition that causes red, scaly patches on the skin. While both psoriasis and lupus are autoimmune disorders, the specific skin manifestations of lupus differ from those of psoriasis. Therefore, a nurse would not expect to find psoriasis in a client with systemic lupus erythematosus.

D) Raised facial rash: A raised facial rash, often described as a "butterfly rash," is a classic manifestation of systemic lupus erythematosus. This rash typically appears across the cheeks and nose and is associated with photosensitivity, making it a key finding when assessing clients with SLE. Thus, the presence of a raised facial rash is an expected and significant finding in this condition.

A. "I will use an enema to manage my constipation." B. "I will remove my shoes when I'm inside my house." C. "I will wipe my nose instead of blowing it." D. "I will floss between my teeth every time I brush."

Correct Answer is C

Explanation

A) "I will use an enema to manage my constipation.": This statement is concerning because enemas can cause trauma to the rectal mucosa, which may lead to bleeding in a client with thrombocytopenia. Therefore, this action is not advisable and indicates a lack of understanding of safe practices.

B) "I will remove my shoes when I'm inside my house.": While removing shoes can help maintain cleanliness, it does not directly relate to managing thrombocytopenia or preventing bleeding. This statement does not reflect an understanding of the specific precautions needed for a client with low platelet counts.

C) "I will wipe my nose instead of blowing it.": This statement demonstrates an understanding of the need to minimize trauma to the nasal passages. Blowing the nose can increase the risk of bleeding in individuals with thrombocytopenia, so wiping is a safer alternative.

D) "I will floss between my teeth every time I brush.": Flossing can be harmful for a person with thrombocytopenia, as it may cause gum bleeding. Clients are often advised to avoid flossing to reduce the risk of bleeding, indicating that this statement reflects a misunderstanding of appropriate oral care practices for their condition.

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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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Correct Answer is C

Explanation

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