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) Increase intake of milk products: Many individuals with irritable bowel syndrome (IBS) may experience lactose intolerance, leading to bloating and discomfort from milk products. Therefore, increasing dairy intake is not typically recommended.
B) Sweeten foods with fructose corn syrup: Fructose can exacerbate symptoms in some people with IBS, as it can lead to digestive upset. Instead, it’s best to limit foods high in fructose corn syrup.
C) Increase intake of foods high in gluten: Gluten may cause issues for individuals with specific sensitivities or celiac disease, and for some with IBS, it may trigger symptoms. Thus, increasing gluten intake is not advisable.
D) Consume foods high in fiber: Increasing dietary fiber is generally recommended for individuals with IBS, as it can help regulate bowel movements and improve overall digestive health. Soluble fiber, in particular, is beneficial and can help alleviate symptoms.
Correct Answer is C
Explanation
A. "You are making progress in your treatment plan." While this response provides positive reinforcement, it doesn't address the client's feelings of frustration or desire to go home, potentially invalidating their emotions.
B. "You should call your partner to discuss this." Suggesting that the client call their partner shifts the focus away from their feelings and may not provide the immediate emotional support they need.
C. "It must be very frustrating for you to be here." This response acknowledges the client's feelings and validates their frustration. It opens the door for further discussion about their emotions, helping the client feel heard and understood.
D. "It would be best to discuss your feelings with your provider." This response may dismiss the client's current feelings by directing them away from the nurse, who is present and capable of providing support. It is important to validate the client's feelings first.
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