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 B

Explanation

A) "Decrease the ventilator flow rate.": Lowering the flow rate may not address the underlying issue causing the high-pressure alarm and could potentially worsen the client's respiratory distress. It is essential to identify and manage the cause first.

B) "Deliver breaths manually with a resuscitation bag.": This is the most appropriate immediate action. Manually providing breaths ensures the client receives adequate ventilation while the nurse assesses the situation. This intervention prioritizes the client's safety and oxygenation during respiratory distress.

C) "Assess for disconnected tubing.": While checking for disconnected tubing is an important step in troubleshooting the alarm, it may take time to assess and does not provide immediate support to the client in respiratory distress. Ensuring adequate ventilation is the priority.

D) "Reevaluate the client for an ET cuff leak.": Evaluating for an ET cuff leak is relevant but is not the most urgent action in this situation. The high-pressure alarm indicates an immediate problem that requires rapid intervention, such as manual ventilation, to stabilize the client.

A. Check the client's vital signs from the previous shift prior to the initiation of the transfusion. B. Administer the blood via a 21-gauge IV needle. C. Set the IV infusion pump to administer the blood over 6 hr. D. Flush the blood administration tubing with 0.9% sodium chloride prior to the transfusion.

Correct Answer is D

Explanation

A) Check the client’s vital signs from the previous shift prior to the initiation of the transfusion: Checking the client’s vital signs from the previous shift is not sufficient. The nurse should obtain a set of baseline vital signs immediately before starting the transfusion to monitor for any changes or reactions during the procedure.

B) Administer the blood via a 21-gauge IV needle: A 21-gauge IV needle is too small for administering packed RBCs. A larger gauge needle, such as an 18- or 20-gauge, is recommended to ensure the blood flows smoothly and to reduce the risk of hemolysis.

C) Set the IV infusion pump to administer the blood over 6 hr: Administering the blood over 6 hours is not appropriate. Packed RBCs should be transfused within 4 hours to reduce the risk of bacterial contamination and ensure the blood remains viable.

D) Flush the blood administration tubing with 0.9% sodium chloride prior to the transfusion: Flushing the blood administration tubing with 0.9% sodium chloride is the correct action. This helps to clear the line of any residual substances and ensures that the blood product is delivered effectively and safely to the client.

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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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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client receiving mechanical ventilation via an endotracheal (ET) tube. The high-pressure alarm is beeping, and the client is experiencing respiratory distress. The nurse is unable to determine the cause of the alarm. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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