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 A
Explanation
A) Determine if the client has thoughts about self-harm: In situations of acute grief and trauma, assessing for suicidal ideation is the priority. The nurse must ensure the client's safety first, as the loss of a partner in such a tragic circumstance can lead to overwhelming feelings of despair and hopelessness.
B) Review the client's available social support system: While understanding the client’s social support is important for ongoing care and coping strategies, it is not the immediate priority. Ensuring the client’s safety takes precedence over evaluating their support network.
C) Empower the client to feel that he is in charge of his life: Empowering the client is a valuable goal for long-term recovery, but it should come after assessing immediate safety and mental health needs. The client may not be in a state to feel empowered until basic concerns about their well-being are addressed.
D) Find the client a temporary shelter where he can feel safe: While finding shelter is crucial for the client’s physical safety and security, this action should follow the immediate assessment of the client’s mental health and any risk of self-harm. Ensuring psychological safety is the first step before addressing logistical needs.
Correct Answer is A
Explanation
A. Negative clonus: Monitoring for a negative clonus is appropriate as it indicates effective control of neuromuscular excitability and seizure prevention in clients receiving magnesium sulfate for preeclampsia. A negative clonus response suggests that the magnesium sulfate is effectively managing the risk of seizures.
B. BP 150/92 mm Hg: While blood pressure management is important in preeclampsia, a blood pressure of 150/92 mm Hg indicates hypertension, which is not a desired therapeutic effect when managing preeclampsia with magnesium sulfate.
C. Pulse rate 100/min: A pulse rate of 100/min is not a specific therapeutic effect of magnesium sulfate and can indicate tachycardia, which might require further evaluation rather than being a target for monitoring.
D. Flushed face: A flushed face may occur as a side effect of magnesium sulfate infusion, but it is not a therapeutic effect. It does not indicate that the medication is working to control the symptoms of preeclampsia.
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