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?

Set up the sterile field 5 cm (2 in) below waist level.

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.

Answer and Explanation

The Correct Answer is D

A: The sterile field should be set up at or above waist level to prevent contamination from higher surfaces, not below.
B: The outer edge (about 2.5 cm or 1 inch) of the sterile field is considered non-sterile, so placing the sterile dressing close to the edge risks contamination.

C: The outermost flap of the sterile kit should be opened away from the body to avoid reaching over the sterile field, which could lead to contamination.
D: The cap should be placed sterile side up to maintain its sterility if it needs to be reapplied to the solution bottle.

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Correct Answer is B

Explanation

A. Monitoring vital signs every 12 hours is a standard nursing intervention but may not specifically address the needs of a client with immunosuppression.
B. Inspecting the client's mouth every 8 hours can help in early detection of mouth sores or infections, which are common in immunosuppressed individuals.
C. Providing fresh fruit with meals may not be appropriate for a client with immunosuppression, as fresh fruits can harbor pathogens that pose a risk of infection.
D. Rotating healthcare staff caring for the client helps increases the risk of introducing pathogens to the client. This increases the risk of infection in the immunosuppressed client.

A. "Use rubbing alcohol to remove the ink markings." B. "You might experience altered taste sensations." C. "Wear a binder over the radiation site." D. "Wash your skin thoroughly with a washcloth after each treatment."

Correct Answer is B

Explanation

A. Using rubbing alcohol to remove ink markings is not recommended as it can irritate the skin, especially in areas undergoing radiation therapy.
B. Altered taste sensations are a common side effect of radiation therapy, especially when the therapy is targeted near the head or neck. The nurse should inform the client about potential changes in taste perception and provide strategies to cope with them.
C. Wearing a binder over the radiation site is unnecessary and may cause discomfort or interfere with treatment.
D. Washing the skin thoroughly with a washcloth after each treatment is not necessary; gentle cleansing with mild soap and water is sufficient.

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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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