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 B

Explanation

A. Physical therapy: Physical therapists focus on improving mobility, balance, and strength. While important after a stroke, they do not primarily address swallowing difficulties.

B. Speech therapy: Speech-language pathologists assess and treat dysphagia (swallowing disorders) and communication difficulties. Referral to speech therapy ensures the client receives appropriate evaluation and interventions to prevent aspiration and maintain nutrition.

C. Respiratory therapy: Respiratory therapists manage airway and pulmonary function issues. They may assist if complications like aspiration pneumonia occur, but they do not directly treat swallowing difficulties.

D. Occupational therapy: Occupational therapists help with activities of daily living and adaptive strategies for self-care. While they may assist with feeding techniques or positioning, they do not specialize in swallowing assessments or interventions.

A. Remind the client to eat scheduled meals daily. B. Place the client in a supine position. C. Offer the client a blanket to keep warm. D. Speak in a loud tone when addressing the client.

Correct Answer is C

Explanation

A. Remind the client to eat scheduled meals daily: Clients nearing the end of life often have a decreased appetite and may be unable or unwilling to eat. Forcing meals can cause discomfort and is not a priority at this stage.

B. Place the client in a supine position: Lying flat can increase the risk of aspiration and respiratory discomfort. Positioning the client for comfort, often semi-Fowler’s or side-lying, is preferred.

C. Offer the client a blanket to keep warm: Clients near the end of life may experience chills or cool extremities due to decreased circulation. Providing a blanket helps maintain comfort and dignity, which is a primary goal of end-of-life care.

D. Speak in a loud tone when addressing the client: Speaking loudly is unnecessary unless the client has hearing impairment. Communication should remain calm, gentle, and respectful to provide reassurance and maintain comfort.

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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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