A nurse is preparing to perform a sterile wound irrigation and dressing change for a client. Which of the following actions by the nurse indicate break in surgical aseptic technique?

Putting on sterile gloves after preparing the sterile field

Placing the supplies on the sterile field and leaving a 1-inch perimeter

Balancing the bottle on the sterile basin while pouring the liquid

Applying a sterile gown after applying a sterile mask

Answer: C.

Answer and Explanation

The Correct Answer is C

A. Putting on sterile gloves after preparing the sterile field: This is correct aseptic practice, as sterile gloves should be donned after the sterile field is prepared to maintain sterility.

B. Placing the supplies on the sterile field and leaving a 1-inch perimeter: Maintaining a 1-inch border around the sterile field is standard practice to avoid contamination. Supplies placed within the field but outside this border remain sterile.

C. Balancing the bottle on the sterile basin while pouring the liquid: Placing a bottle on a sterile field risks contaminating the field if the bottle is not sterile. This action constitutes a break in surgical aseptic technique.

D. Applying a sterile gown after applying a sterile mask: Donning a mask before the sterile gown is appropriate to prevent contamination of the sterile gown during placement. This does not break aseptic technique.

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Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

Rationale for correct choices:

Obtain IV access: The client has hypotension (BP 90/50 mm Hg), tachycardia (HR 118/min), and significant anemia (Hgb 9.1 g/dL, Hct 27%), all of which suggest possible active gastrointestinal bleeding. Establishing IV access is a priority to allow rapid fluid resuscitation or blood product administration as needed.
Prepare for a blood transfusion: Given the positive hemoccult stool, anemia, and vital sign changes, the client may require a blood transfusion to restore hemodynamic stability and oxygen-carrying capacity. Preparing for transfusion ensures timely intervention in case of worsening blood loss.

Rationale for incorrect choices:

Call the surgical suite to notify that the client is arriving STAT: While the client is scheduled for endoscopy, immediate stabilization takes priority over notifying the surgical suite. The client’s hemodynamic status must be addressed first to prevent deterioration.
Recheck the client's oxygen saturation: The client’s oxygen saturation is 98% on room air, which is within normal limits. Rechecking is not immediately necessary and does not address the urgent need for stabilization.
Place the client in a supine position with feet elevated: Although elevating the feet can help improve perfusion temporarily, it does not treat the underlying anemia or hypotension and is less urgent than establishing IV access and preparing for transfusion.
Offer oral fluids: Oral intake is contraindicated in a client at risk for endoscopy and possible GI bleeding. Fluids could increase the risk of aspiration and do not address hemodynamic instability.
Administer PRN antacids: Antacids may provide minor symptom relief but do not treat active blood loss or stabilize the client before endoscopy.
Document vital signs: Documentation is important but secondary to immediate interventions that address the client’s hypotension and potential hemorrhage.

A. Current fecal impaction B. Present report of abdominal pain C. Thrombophlebitis D. Diverticulitis

Correct Answer is C

Explanation

Rationale:

A. Current fecal impaction: While fecal impaction requires treatment, it is not related to the safety or pharmacologic effects of conjugated estrogen therapy and does not constitute a contraindication.

B. Present report of abdominal pain: Abdominal pain requires evaluation, but it is nonspecific and not an absolute contraindication to conjugated estrogen unless related to certain underlying conditions like liver disease or cancer.

C. Thrombophlebitis: Estrogen increases the risk of thromboembolic events by promoting clot formation. A history or presence of thrombophlebitis makes estrogen therapy unsafe due to the elevated risk of worsening venous thromboembolism.

D. Diverticulitis: Diverticulitis is an inflammatory bowel condition that is not directly affected by estrogen therapy. It would not typically prohibit the use of conjugated estrogen unless complications or comorbidities present additional risks.

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A nurse is preparing to perform a sterile wound irrigation and dressing change for a client. Which of the following actions by the nurse indicate break in surgical aseptic technique?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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